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COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

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PLASTIC  SURGERY 

DAVIS 


PLASTIC  SURGERY 


ITS 

PRINCIPLES  AND  PRACTICE 


BY 
JOHN  STAIGE  DAVIS,  Ph.B.,  M.D.,  F.A.C.S. 

INSTRUCTOR  IN   CLINICAL  SURGERY,  JOHNS   HOPKINS   UNIVERSITY;   ASSISTANT  VISITING    SURGEON", 

JOHNS  HOPKINS   hospital;  visiting  SURGEON  AND   PLASTIC  SURGEON   TO  THE  UNION 

PROTESTANT   INFIRMARY,   THE   HOSPITAL  FOR  THE   WOMEN   OF  MARYLAND,   AND 

THE   children's   HOSPITAL  SCHOOL,  BALTIMORE,  MD.;  FELLOW   OF 

THE     AMERICAN     SURGICAL     ASSOCIATION;     THE 

SOUTHERN  SURGICAL  ASSOCIATION;   ETC. 


WITH  864  ILLUSTRATIONS  CONTAIXIXG  1637  FIGURES 


PHILADELPHIA 
P.  BLAKISTON'S  SON  &  CO. 

1012  WALNUT  STREET 


Copyright,  1919,  by  P.  Blakiston's  Son  &  Co. 


T?  J)  w^ 
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THE     MAP 


LE     PRESS     YORK     F  ■ 


X5o 

K.  B.  D. 


WHOSE  GOOD  COUNSEL  AND  NEVER  FAILING 
ENCOURAGEMENT  HAS  MEANT  SO  MUCH 
TO  ME  IN  THE  UPS  AND   DOWNS  OF  LIFE. 


PREFACE 

About  ten  years  ago  my  friend  Dr.  J.  M.  T.  Finney,  who  knew  of 
my  interest  in  plastic  surgery,  suggested  that  I  specialize  in  this  work. 
He  said  that  every  general  surgeon  was  operating  on  these  cases  because 
they  had  to  be  taken  care  of,  but  that  no  one  in  this  country  was  doing 
the  work  properly  and  that  the  field  was  undeveloped. 

As  a  result  this  book  has  been  written  to  record  my  personal  ex- 
perience and  also  to  collect  from  scattered  sources,  and  place  in  an 
accessible  form  the  principles  and  methods  that  have  been  of  use  to  me. 

It  is  my  hope  that  this  book  may  show  the  general  practitioner  the 
possibilities  of  plastic  surgery,  and  start  the  student  or  beginner  in 
this  subject  on  the  right  track.  The  more  experienced  surgeon  may 
also  find  methods  with  which  he  is  unfamiliar,  and  which  may  be  of 
use  to  him  in  dealing  with  plastic  cases. 

The  teaching  of  this  subject  has  been  absolutely  neglected  every- 
where, both  for  medical  students  and  for  post-graduates.  There  is  as 
yet  no  department  for  instruction  of  this  kind  in  any  American  Uni- 
versity, and  no  complete  text-book  has  hitherto  been  written  on  the 
subject. 

It  has  been  commonly  said  that  any  surgeon  who  can  successfully 
do  an  intestinal  suture  can  do  plastic  surgery.  Careful  investigation 
of  this  point  warrants  the  statement — without  qualification — that  few 
general  surgeons  do  plastic  surgery  as  it  should  be  done.  The  possi- 
bihties  are  Httle  understood  by  the  practising  physician,  and  hardly 
more  by  the  general  surgeon. 

The  time  has  come  for  the  separation  of  plastic  surgery  from  the 
general  surgical  tree.  There  should  be  a  well-trained  plastic  surgeon 
on  the  staff  of  every  large  general  hospital,  in  order  that  these  patients 
may  be  cared  for  intelligently. 

During  the  war  (1914-1918)  plastic  surgery  was  arbitrarily  limited, 
by  regulation,  to  maxillo-facial  reconstruction.  This,  it  is  true,  is  a 
very  important  part  of  the  subject,  but  it  must  be  remembered — and 
the  fact  should  be  emphasized — that  plastic  surgery  of  the  trunk  and 
extremities  is  equally  important.  The  results  may  be  less  spectacular, 
but  surely  are  just  as  vital  to  the  patient.  The  field  of  plastic  surgery 
extends  from  the  top  of  the  head  to  the  sole  of  the  foot,  and  no  properly 

vii 


Vlll  PREFACE 

trained  plastic  surgeon  would  be  willing  to  limit  his  work  to  the  face 
alone. 

Except  for  the  progress  made  in  the  treatment  of  recent  wounds  of 
the  face  (especially  those  associated  with  fractures  and  loss  of  substance 
of  the  jaws — which  are  seldom  if  ever  referred  to  the  plastic  surgeon  in 
civil  practice)  little  or  no  advance  has  been  made  in  plastic  methods 
during  the  war.  The  true  plastic  problems  are  much  the  same  as  those 
which  must  be  solved  in  civil  practice,  although  they  may  be  new  to 
the  surgeon  hitherto  unfamiliar  with  plastic  methods. 

The  list  of  publications,  selected  from  those  consulted,  found  at  the 
end  of  each  chapter  will  supply  a  good  working  basis  for  the  reader  who 
wishes  to  delve  more  deeply  into  that  particular  subject.  When  the 
same  author  has  been  quoted  in  more  than  one  chapter,  repetition  of 
the  reference  has  been  avoided  as  far  as  possible,  but  the  source  of 
information  may  be  obtained  by  consulting  the  bibliographical  index. 

Many  of  the  illustrations  have  been  taken  from  my  own  collection; 
others  (most  of  which  are  diagrammatic)  have  been  selected  from  various 
sources  to  demonstrate  some  condition,  definite  point,  or  method,  and 
are  self-explanatory. 

I  have  made  every  effort  to  give  due  credit  to  all  those  whose  writ- 
ings or  diagrams  have  been  of  use  to  me  in  the  preparation  of  this  work; 
any  omissions  are  unintentional. 

Should  certain  critics  feel  that  I  have  encroached  upon  other 
branches  of  surgery  in  some  of  the  subjects  considered,  a  study  of  the 
text  of  these  chapters  will,  I  think,  modify  this  opinion. 

In  the  preparation  of  the  book  I  have  drawn  with  considerable 
freedom  from  the  following:  "La  Rhinoplastie,"  Nelaton  and  Ombre- 
danne,  1904;  "Les  Autoplastics,"  Nelaton  and  Ombredanne,  1907;  "La 
Chirurgie  Reparative  de  la  Face,"  Depage,  1905;  Plastic  Surgery,  J.  S. 
Stone,  in  Bryant  and  Buck's  "American  Practice  of  Surgery,"  iv,  610; 
"a  System  of  Ophthalmic  Operations,"  Wood,  191 1;  "Ophthalmic 
Surgery,"  Beard;  the  numerous  articles  of  the  brilliant  French  plastic 
surgeon,  H.  Morestin,  and  many  other  sources. 

I  wish  to  express  my  thanks  to  friends  who  have  referred  interesting 
plastic  cases  to  me;  to  Dr.  W.  S.  Halsted,  for  permission  to  use  material, 
much  of  which  has  come  under  my  care,  from  the  surgical  clinic  of  the 
Johns  Hopkins  Hospital;  to  Dr.  Frank  R.  Smith,  for  his  help  in  super- 
vising the  manuscript;  to  Dr.  I.  W.  Nachlas,  for  tabulating  the  cases  of 
harelip  and  cleft  palate  at  the  Johns  Hopkins  Hospital;  to  my  secretary, 
Miss  Johnetta  Moore,  for  her  intelligent  cooperation  and  tireless  work 


PREFACE  IX 

in  the  prei)arati()n  of  this  book;  to  Miss  Minnie  W.  Blogg,  the  Hbrarian 
at  the  Johns  Hopkins  Hospital,  and  Miss  Marcia  C.  Noyes,  the  Hbrarian 
of  the  Medical  and  Chirurgical  Faculty  of  Maryland,  for  their  unfailing 
courtesy  in  making  possible  the  examination  of  the  large  number  of 
references  consulted;  and  to  the  publishers,  who  have  cooperated  with 
me  in  every  way  possible. 

If  this  book  should  prove  of  use  in  bringing  relief  to  any  one  of  our 
wounded  soldiers  who  require  the  aid  of  the  plastic  surgeon,  I  shall 
feel  fully  repaid  for  the  time  spent  in  its  preparation. 

John  Staige  Davis. 

1200  Cathedral  St., 

Baltimore,  Md. 

July,  iqiq-, 


I 


CONTENTS 


Page 
Preface vii 

CHAPTER  I 

HISTORICAL  REVIEW 

Development  of  Rhinoplastic  and  Other  Plastic  Operations;  Italian  method; 
Indian  method;  French  method;  Dex'elopment  of  Skin  Transplantation; 
Reverdin;  Ollier-Thiersch;  Wolfe-Krause i 

CHAPTER  II 

GENERAL  CONSIDERATIONS 

Definition;  Importance  of  general  surgical  training;  Necessity  of  knowledge  of  tissue 
transplantation;  Definition  of  terms;  Methods  of  closing  defects;  Preparation 
of  the  part;  Anesthesia;  Incisions  and  methods  of  closure;  Needles  and  suture 
materials;  Methods  of  closing  wounds  without  suturing;  Hemorrhage;  Drain- 
age; Dressings;  Infections;  Massage  and  passive  motion;  Graphic  records.    .      12 

CHAPTER  III 

PROSTHESIS 

External,  Methods  and  materials  used;  Internal,  Methods  and  materials  used; 

SUBCUTAN-Eous  H\'drocarbon  Prosthesis;  Untoward  results 36 

CHAPTER  IV 

THE  TRANSPLANTATION  OF  SKIN 

General  Considerations;  Source  of  grafts;  Autografts;  Isografts;  Zoo-grafts; 
Anaphylactic  symptoms;  Transplantation  of  fetal  membranes;  Surface  on 
which  grafts  may  be  placed;  Preparation  of  the  granulating  area;  Method  of 
preparing  healthy  granulations;  Anesthesia;  Dressing  of  the  area  from 
which  the  graft  is  cut;  Small  Deep  Skin  Gr.afts;  Technic;  Post-operative 
treatment;  Untoward  possibilities;  Ollier-Thiersch  Grafts;  Source;  Tech- 
nic; Dressings;  Method  of  splinting  skin  grafts;  Untoward  possibilities; 
Results;  Special  ^Iethods;  Buried  grafting;  Method  of  securing  two  grafts 
from  the  same  area;  Whole-thickn-ess  Grafts;  Preparation  of  area;  Tech- 
nic; Dressings;  Transplantation  of  hair-bearing  skin;  Histological  changes; 
Changes  in  pigmentation 49 

CHAPTER  V 

THE  TRANSPLANTATION  OF  OTHER  TISSUES 

Fascia;  Bone;  Cartilage;  Fat;  Mucous  membrane;  Tendons;  Nerves;  Vitality  of  grafts; 

Method  of  preservation 100 

xi 


XU  CONTENTS 

Page 
CHAPTER  VI 

PEDUNCULATED  FLAPS 

French  method;  Indian  method;  Italian  method;  Transference  of  the  Flap;  Single 
or  multiple;  Type  of  Flap;  Simple  or  compound;  Double-faced  flaps;  Sym- 
biotic transplantation;  Important  Suggestions;  Scarification  of  flaps; 
Methods  of  assuring  the  blood  supply;  Mucous  membrane;  Fat;  Muscle; 
Fascia 113 

CHAPTER  VH 

THE  TREATMENT  OF  WOUNDS 

General  Considerations;  Recent  wounds,  with  and  without  destruction  of  bone; 
Debridement;  Primary-delayed  primary- secondary  sutures;  Dressings  for 
sutured  wounds;  Granulating  wounds;  Classification  of  burns;  Mustard  gas 
burns;  Care  of  surrounding  skin;  Avoidance  of  pain;  Anesthesia;  Method  of 
sponging;  Protection  of  granulations;  Exuberant  granulations;  The  Chlor- 
ine Antiseptics;  Dakin's  solution;  Carrel  technic;  Eusol;  Dichloramine-T; 
Quino-formol;  Ointments;  Powders;  Medicated  gauze;  Excision;  Wet 
dressings;  Continuous  tub;  Parafiin  wax;  Adhesive  plaster;  Open  treat- 
ment; Heliotherapy;  Hot  air;  Balsam  of  Peru;  Embalmment  treatment; 
Ether  as  a  dressing;  Glycerine;  lodin;  The  Bipp  treatment;  Salt  packs 
and  sea  water;  Normal  serum;  Use  of  soap;  Two-route  method;  Massage  and 
passive  motion;  Organic  Coloring  Matters;  For  the  stimulation  of  epithe- 
lium; For  antiseptic  use 130 

CHAPTER  VHI 

INTRACTABLE  ULCERS  AND  VARICOSE  VEINS 

Intractable  Ulcers;  Routine  history;  Painful  ulcers;  Operative  treatment;  Nerve 
stretching;  X-ray  or  radium;  Etiology  of  leg  ulcers;  Non-operative  Treat- 
ment; Adhesive  plaster  support;  Rubber  bandage;  Pressure  bandage;  Gelatin 
cast;  Canvas  legging  and  elastic  stocking;  Varicose  Veins;  Operative  treat- 
ment; Skin  grafts  in  the  ambulatory  treatment  of  ulcers;  Ulcers  in  scars; 
Chronic  ulcers  in  the  groin;  X-ray  burns;  Radium  burns;  Burns  from  elec- 
tricity; Hot-water  bag  burns;  Ice-bag  burns 178 

CHAPTER  IX 

SCARS  AND  KELOIDS 

Types  of  Scars;  Depressed;  Extensive  unstable;  Extensive  smooth;   Contracted; 

Tattooed  skin  and  powder  marks;  ELeloid;  Methods  of  treatment 206 

CHAPTER  X 
MALFORMATIONS 


Hemangioma;  Capillary;  Arterial;  Venous;  Cavernous;  Methods  of  treatment; 
Lymphangioma;  Methods  of  treatment;  Hypertrophy  of  the  Tongue; 
Treatment;  Hypertrophy  of  the  Lips;  Treatment;  Moles;  Treatment; 
Supernumerary  Digits;  Treatment;  Syndactylism;  Methods  of  treatment; 
Hammer-toe;  Treatment 22 


I 


CONTENTS  Xlll 

Page 
CHAPTER  XI 

HARELIP  AND  CLEFT  PALATE 

Incidence;  Varieties  of  harelip;  Varieties  of  cleft  palate;  Proper  sequence  of  operative 
procedures;  Time  of  operation;  Preliminary  care;  Anesthesia;  Preparation; 
Treatment  of  Harelip;  Method  of  suturing;  Dressings;  Prominent  inter- 
maxillary process;  Complications  in  harelip;  Post- operative  care;  Secondary 
operations  for  harelip;  Treatment  of  Cleft  Palate;  Necessary  apparatus; 
Technic;  Edgc-to-edge  method;  Two-stage  edge-to-edge  method;  Post-opera- 
tive care;  Complications  in  cleft  palate;  The  forcible  approximation  of  the 
edges,  Brophy  and  Blair;  The  turnover  flap  method,  Davics-Colley,  and  Lane; 
Secondary'  operations  for  cleft  palate;  Transplantation  of  extrapalatal  tissues; 
Obturators;  Training  in  articulation 253 

CHAPTER  Xn 
EXSTROPHY  OF  THE  BLADDER  (ECTOPIA  VESICAE) 

Time  of  operation;  Methods  of  treatment;  The  diversion  of  the  urinary  stream  to  the 
urethra,  vagina,  or  skin  surface;  The  diversion  of  the  urinary  stream  into  the 
rectum;  Bottomley's  operation  for  transplanting  the  ureters  to  the  skin  of 
the  loin;  Moynihan's  operation  of  transplanting  the  bladder  into  the  rectum; 
C.  H.  Mayo's  operation  for  implantation  of  the  free  ureters  into  the  sigmoid.    298 

CHAPTER   XIII 
EPISPADIAS 

Time  of  operation;  Preliminary  steps;  Methods  of  treatment;  Thiersch's  operation; 

Cantwell's  operation;  Young's  operation;  Epispadias  in  the  female   .    .    .    .310 

CHAPTER  XIV 
HYPOSPADIAS 

Varieties;  Time  of  operation;  Methods  of  treatment;  Beck's  operation;  Bevan's  opera- 
tion; Duplay's  operation;  Bucknall's  operation;  Russell's  operation;  Method 
of  choice 316 

CHAPTER  XV 
ATRESIA  OF  THE  VAGINA 

Acquired;  Congenital;  Methods  of  treatment;  Formation  of  the  vagina  with  peduncu- 
lated flaps  of  skin,  etc.;  Formation  of  the  vagina  by  means  of  intestinal 
transplantation;  Baldwin's  operation 336 

CHAPTER  XVI 
PLASTIC  SURGERY  AS  APPLIED  TO  THE  VARIOUS  REGIONS 

General  Considerations;  Surgery  of  the  Scalp  and  Skull;  Scalp;  Avulsion;  Etiology; 
Treatment;  In  smaller  defects;  In  ulcers;  Angiomata;  Fibrous  growths; 
Keloids;  Defects  associated  with  bone  necrosis;  Skull;  Methods  of  closing 
defects;  With  periosteal,  osteoperiosteal,  and  cutaneous  osteoperiosteal  flaps; 
Decalcified  bone,  iso-bone,  etc.;  Prosthetic  method;  Fascia  and  skin;  Car- 
tilage and  bone  grafts 343 


XIV  CONTEXTS 

Page 
CHAPTER  XVII 

SURGERY  OF  THE  EYELIDS  (BLEPHAROPLASTY) 

Recent  wounds;  Entropion;  Methods  of  treatment;  Ectropion;  Methods  of  treatment; 
Restoration  of  the  lower  lid;  Preparation  of  new  socket  for  an  artificial  eye; 
Canthoplasty;  Tarsorrhaphy;  Exenteration  of  the  orbit;  Restoration  of  the 
eyebrow;  Ptosis;  Epicanthus;  Relief  of  occlusion  of  the  naso-lachrymal  duct .   358 

CHAPTER  XVni 

SURGERY  OF  THE  EAR  (OTOPLASTY) 

Congenital  malformations;  Acquired  defects;  Injuries;  Malformations  of  the  lobule; 
Macrotia;  Absence  of  the  ear;  ^licrotia;  Artificial  ears;  Perforations  of  the 
auricle;  Retro-auricular  fistulae  and  depressions;  Reconstruction  of  the  ex- 
ternal auditory-  canal;  Abnormal  prominence  of  the  auricle;  Smooth,  flat- 
tened ears;  Abnormal  contour  of  the  auricle 394 

CHAPTER  XIX 

SURGERY  OF  THE  EXTERNAL  NOSE  ^RHINOPLASTY) 

Recent  injuries;  Replacement  of  the  nose;  Losses  of  substance;  Recent  fractures;  Old 
fractures;  RhjmophjTna;  Angioma;  R htxoplastic  Methods :  Indian,  French, 
Italian,  double-flap  method;  Reconstruction  of  the  Feamework:  Osteo- 
periosteal support,  CartilaguiGus  support;  S.iddle  Xose;  ]\Iethods  of  treat- 
ment; Use  of  the  finger  in  rhinoplasty;  Restoration  of  the  Lower  Part 
OF  THE  Xose;  Operations  for;  Restoration  of  the  Tip  of  the  Xose; 
Operations  for;  Restoration  of  the  Coluhna;  Operations  for;  Secondary- 
rhinoplastic  operations;  Oblique  nose;  To  reduce  the  size  of  the  nose;  To 
lengthen  the  nose;  To  narrow  the  nose;  To  raise  a  flattened  nostril;  To 
lengthen  the  ala;  To  reduce  the  thickness  of  the  ala;  Atresia  of  the  nostrils; 
Absence  of  nose,  congenital;  Reduction  of  thickened  columna,  and  advancing 
the  point  of  the  nose;  Correction  of  lobe  defects;  Bifld  nose 428 

CIL\PTER  XX 

PLASTIC  SURGERY  OF  THE  JAWS,  LIPS  AND  CHEEKS 

Gen'eral  Considerations;  Anesthesia;  Preparation;  Surgery  of  the  Jaw"S;  Recent 

injuries;  Extensive  destruction  of  the  mandible  and  the  soft  parts;  Recon-         | 
struction  of  the  Superior  M.axilla;  Reconstruction  of  the  ]Mant)ible; 
The  use  of  bone  or  cartilage  grafts;  Use  of  pedunculated  flaps  ■with  bone 
attached;  Irregularities  of  the  mandible;  Reconstruction  of  the  orbital  rim, 
and  the  malar  bone  following  injur>-;  Depressed  fractures  of  the  malar  bone.  497 

CHAPTER  XXI 

SURGERY  OF  THE  LIPS  fCHEILOPLASTY) 

General  considerations;  Restor.a.tion  of  the  Upper  Lip;  Immediate  reconstruction; 
Use  of  unilateral,  bilateral,  or  flaps  from  distant  parts;  Secondary  re- 
construction; Restoration  of  the  Lower  Lip;  Immediate  reconstruction; 
Unilateral,  bilateral,  or  flaps  from  distant  parts;  Buttressed  flaps;  Secondary' 
restoration;  Lesions  of  both  lips;  Reconstruction  of  the  vermilion  border; 
Reconstruction  of  the  commissures;  Constriction  of  the  buccal  orifice; 
Abnormally  large  mouth;  Ectropion  of  the  lips;  Cheilorrhaphy 510 


CONTENTS  XV 

Page 

CHAPTER  XXII 

I 

SURGERY  OF  THE  CHEEK  (MELOPLASTY) 

Loss  of  substance;  Superficial  wounds;  Repair  of  defects  in  the  mucosa;  Repair  of  de- 
fects involving  full  thickness  of  the  cheek;  Methods  of  treatment;  Cicatricial 
contracture  of  the  Jaws;  Angioma;  Depressed  scars;  Salivary  Fistula: 
Glandular:  Treatment;  Stenson's  duct:  Treatment;  Facial  Paralysis;  Ele- 
vation of  lower  eyelid;  Elevation  of  angle  of  the  mouth;  Elevation  by 
myeloplasty 565 

CHAPTER  XXIII 

SURGERY  OF  THE  NECK,  TRUNK  AND  EXTREMITIES 

General  Considerations;  Surgery  of  the  Neck;  Contractures;  Treatment  by 
gradual  stretching;  Division  of  scar  tissue;  Pedunculated  flaps;  Skin  grafts; 
Tracheal  Defects;  Methods  of  treatment;  Surgery  of  the  Trunk;  Clos- 
ure of  defects  after  amputation  of  the  breast;  Closure  of  defects  on  the  trunk; 
Relief  of  adhesion  between  the  arm  and  thoracic  wall;  Methods  of  recon- 
struction of  the  axilla;  Preservation  of  contour  of  breast;  Hernia  of  the  lung.   606 

CHAPTER  XXIV 

SURGERY  OF  THE  EXTREMITIES 

General  Considerations;  Treatment  of  loss  of  substance;  Treatment  of  vicious 
cicatrices;  Methods  of  obliterating  bone  defects;  Surgery  of  the  Upper 
Extremity;  Arm  and  Elbow;  Loss  of  substance;  Contractures;  Forearm; 
Loss  of  substance;  Contractures;  Wrist;  Loss  of  substance;  Contractures; 
Hand;  Loss  of  substance;  Contractures;  Utilization  of  metacarpal  bones  in 
formation  of  movable  stumps;  The  Fingers;  Loss  of  substance;  Method  of 
lengthening  the  finger  by  the  use  of  the  celluloid  tube;  Method  of  lengthen- 
ing the  linger  by  the  use  of  pedunculated  flaps;  Contractures;  Methods  of 
treatment;  Dupuytren's  Finger  Contraction;  Etiology;  Treatment;  Trans- 
plantation of  fingers  and  toes  to  replace  fingers;  Tendon  involvement;  Exposed 
tendons 639 

CHAPTER  XXV 

SURGERY  OF  THE  LOWER  EXTREMITY 

Loss  OF  Substance;  Thigh,  knee,  leg,  ankle  and  foot;  Contractures;  Thigh  and  leg, 
ankle  and  foot;  Amputations;  Aperiosteal  method;  Unhealed  amputation 
stumps;   Kinematic  plastics;  Elephantiasis;  Etiology;  Treatment 688 


PLASTIC    SURGERY 

CHAPTER  I 
HISTORICAL  REVIEW 

THE  DEVELOPMENT  OF  RHINOPLASTIC  AND  OTHER 
PLASTIC  OPERATIONS 

The  history  of  plastic  surgery  is  closely  associated  with  the  develop- 
ment of  rhinoplastic  operations,  and  nearly  all  of  the  procedures  used 
have  originally  been  employed  in  the  process  of  this  development. 
]Many  years  before  plastic  surgery  was  attempted  in  Europe,  certain 
members  of  the  Tilemaker  caste  in  India  obtained  wonderful  results  in 
plastic  operations  with  pedunculated  flaps  from  the  cheek  and  later 
from  the  forehead,  in  the  reconstruction  of  amputated  noses.  This  is 
known  as  the  Indian  Method. 

They  are  also  said  to  have  occasionally  used  successfully  for  the  same 
purpose  free  flaps  of  skin  taken  from  the  gluteal  region  including  the 
subcutaneous  fat,  after  it  had  been  beaten  with  wooden  slippers  until  a 
considerable  amount  of  swelling  had  taken  place.  They  used  a  secret 
cement  for  the  adhesion,  to  which  was  ascribed  special  healing  power. 
This  is  called  the  Ancient  Indian  Method. 

Here,  then,  is  the  earliest  record  of  whole-thickness  grafting,  and 
antedates  by  centuries  the  work  of  Wolfe,  Krause  and  others. 

It  is  interesting  to  note  that  plastic  surgery  was  practised  in  ancient 
India  and  Egypt,  as  is  shown  by  the  sacred  writings  of  India,  and  in 
Ebers'  Papyrus,  in  both  of  which  rhinoplasty  is  mentioned  as  a  well- 
known  procedure. 

Celsus  speaks  of  the  restoration  of  ears,  noses  and  lips,  with  the  aid  of 
the  neighboring  skin,  and  Galen,  Antyllus  and  Paul  of  Aegina  also 
mention  these  operations. 

Then  for  many  years  the  art  of  plastic  surgery  seems  to  have  been 
lost,  at  any  rate  to  European  surgeons. 

In  the  middle  of  the  fifteenth  century,  about  1442,  Branca  (or 
Brancas),  a  Sicilian  surgeon,  was  able  to  build  noses  by  taking  pedun- 
culated flaps  from  the  skin  of  the  face,  and,  following  him,  his  son  Anto- 


2  PLASTIC    SURGERY 

nius  is  said  to  have  restored  a  lost  nose  by  using  a  flap  from  the  arm. 
The  first  report  of  the  employment  of  the  arm  flap  in  medical  literature 
is  a  brief  note  found  in  a  work  on  anatomy  by  Alexander  Benedictus, 
published  in  Venice  in  1497.  Other  surgeons  of  more  or  less  repute  were 
impressed  with  this  work,  and  various  allusions  to  the  operation  are 
to  be  found  in  surgical  works  of  the  sixteenth  century. 

The  work  of  Caspar  Tagliacozzi  (i 546-1 599)  published  in  1597,  was 
the  first  systematic  treatise  on  plastic  surgery  and  was  entitled  "De 
Curtorum  Chirurgia  per  Insitionem,"  a  volume  of  298  pages  including 
22  full-page  plates.  In  it  he  described  several  operations,  but  gives 
special  prominence  to  his  method  of  rhinoplasty,  in  which  he  used  a 
pedunculated  flap  from  the  arm. 

Two  parallel  incisions  about  20.  cm.  long  (8  inches)  and  10.  cm.  apart 
(4  inches)  were  made  down  to  the  fascia  on  the  anterior  aspect  of  the 
left  arm.  The  flap  was  separated  from  the  fascia,  and  was  kept  away 
from  its  bed  with  oiled  linen,  but  the  pedicles  at  each  end  were  not 
divided.  After  a  fortnight  when  granulation  and  thickening  had 
occurred,  the  upper  pedicle  was  cut  and  the  flap  was  sutured  into 
the  defect,  after  the  edges  had  been  revivified.  The  arm  was  held  in 
position  by  a  special  harness,  and  after  three  weeks  the  other  pedicle 
was  amputated  from  the  arm,  and  the  flap  was  shaped  and  fitted  into 
the  desired  position.     This  is  called  the  Tagliacotian  or  Italian  Method. 

The  pupils  of  Tagliacozzi  continued  to  carry  out  his  method,  but 
within  a  few  years  it  was  lost  sight  of,  and  in  course  of  time  began  to 
be  considered  impossible. 

Reneaulme  de  la  Garanne  (17 12)  tried  to  rehabilitate  the  method, 
and  proposed  sewing  into  the  defect  the  fresh  flap,  immediately  after 
raising  it  without  waiting  for  it  to  granulate.  Despite  his  work,  how- 
ever, the  art  remained  lost  to  practical  surgery  until  1816,  when  v. 
Graefe  again  revived  Tagliacozzi's  method,  and  reported  one  successful 
case.  He  modified  the  procedure  by  cutting  the  upper  pedicle  at  once 
and  by  sewing  the  fresh  flap  into  its  place  without  waiting  for  it  to 
granulate;  thus  making  of  it  a  single  operation. 

The  Indian  method  was  brought  to  the  attention  of  European 
surgeons  by  a  letter  which  was  printed  in  the  Gentleman^ s  Magazine 
for  October,  1794,  p.  891,  a  part  of  which  is  as  follows: 

"  Cowasjee,  a  Mahratta  of  the  caste  of  husbandmen,  was  a  bullock  driver  with 
the  EngUsh  army  in  the  war  of  1792,  and  was  made  a  prisoner  by  Tippoo,  who  cut 
off  his  nose  and  one  of  his  hands.  In  this  state  he  joined  the  Bombay  army  near 
Seringapatam,  and  is  now  a  pensioner  of  the  Honourable  East  India  Company. 


HISTORICAL    REVIEW  3 

For  about  twelve  months  he  remained  without  a  nose,  when  he  had  a  new  one  put  on 
by  a  man  of  the  brickmaker  caste,  near  Poonah.  This  operation  is  not  uncommon 
in  India,  and  has  been  practiced  from  time  immemorial.  Two  of  the  medical 
gentlemen,  ]\Ir.  Thomas  Cruso,  and  Mr.  James  Trindlay,  of  the  Bombay  Presidency, 
have  seen  it  performed  as  follows:  A  thin  plate  of  wax  is  fitted  to  the  stump  of  the 
nose,  so  as  to  make  a  nose  of  a  good  appearance.  It  is  then  flattened  and  laid  on 
the  forehead.  A  line  is  drawn  around  the  wax,  and  the  operator  then  dissects  off 
as  much  skin  as  it  covered,  leaving  undivided  a  small  slip  between  the  eyes.  This 
slip  preserves  the  circulation  till  an  union  has  taken  place  between  the  new  and  old 
parts.  The  cicatrix  of  the  stump  of  the  nose  is  next  pared  off,  and  immediately 
behind  this  raw  part  an  incision  is  made  along  the  upper  lip.  The  skin  is  now 
brought  down  from  the  forehead,  and  being  twisted  half  around,  its  edge  is  inserted 
into  this  incision,  so  that  a  nose  is  formed  with  a  double  hold  above,  and  with  its 
alas  and  septum  below  fixed  in  the  incision.  A  little  terra  japonica  is  softened  with 
water,  and  being  spread  on  slips  of  cloth,  five  or  six  of  these  are  placed  over  each 
other  to  secure  the  joining.  No  other  dressing  but  this  cement  is  used  for  four  days. 
It  is  then  removed,  and  cloths  dipped  in  ghee  (a  kind  of  butter)  are  applied.  The 
connecting  slips  of  skin  are  divided  about  the  twenty-fifth  day,  when  a  little  more 
dissection  is  necessary  to  improve  the  appearance  of  the  new  nose.  For  five  or 
six  days  after  the  operation  the  patient  is  made  to  lie  on  his  back;  and  on  the  tenth 
day  bits  of  soft  cloth  are  put  into  the  nostrils  to  keep  them  sufiiciently  open.  This 
operation  is  very  generally  successful.  The  artificial  nose  is  secure,  and  looks 
nearly  as  well  as  the  natural  one;  nor  is  the  scar  on  the  forehead  very  observable 
after  a  length  of  time." 

J.  C.  Carpue  of  London  was  the  first  surgeon  to  make  use  of  this 
information  and,  in  1814  and  again  in  181 5,  he  successfully  performed 
rhinoplasty  by  the  Indian  method.  Since  that  time  the  operation  has 
been  performed  many  times  and  numerous  modifications  of  the  original 
method  have  been  tried. 

Biinger  in  Marburg  in  1823  was  successful  in  making  a  new  nose  with 
a  free  flap  of  skin  from  the  patient's  thigh,  thus  being  the  first  European 
surgeon  to  carry  out  successfully  the  old  Indian  method.  Graefe  did 
not  succeed  with  his  attempts  at  rhinoplasty  with  free  flaps,  and 
Walther,  Dieffenbach  and  Wertzer  were  scarcely  more  successful.  In 
spite  of  discouraging  results,  these  and  other  surgeons  continued  to 
experiment  in  rhinoplastic  and  other  plastic  operations,  with  varying 
success. 

Rhinoplasty  by  gliding  lateral  facial  flaps  over  the  defect  is  called 
the  French  method,  although  for  the  fundamental  principle  we  are  in- 
debted to  Celsus.  The  utilization  of  it  in  all  sorts  of  plastic  work  is 
invaluable.  It  was  developed  by  Larrey,  Dieffenbach,  Bouisson, 
Baudens,  Burow,  Mlitter,  Szymanowski,  and  others. 

Dieffenbach,  in  his  work  and  by  his  writings,  gave  a  tremendous 


4  PLASTIC    SURGERY 

stimulus  to  plastic  surgery;  many  of  his  methods  have  not  been  im- 
proved upon  and  are  still  constantly  used.  He  advocated  the  granu- 
lating flap  in  the  Italian  method  of  rhinoplasty  and  advised  strongly 
against  the  use  of  the  fresh  flap  suggested  by  Graefe. 

A  number  of  names  may  be  mentioned  in  connection  with  the 
development  of  plastic  surgery,  among  them  being  those  of  Dupuytren, 
Ricard,  Velpeau,  Labat,  Blandin,  Denonvilliers,  Hoffacher,  Schuh, 
Zeiss,  Burggraeve,  Serre,  Liston,  Verhaeghe,  Jobert,  von  Ammon,  Fer- 
gusson,  Ph.-J.  Roux,  Denuce,  Langenbeck,  Gurdon  Buck,  Verneuil, 
Czerny,  Pollock,  Konig,  Tiffany,  Gerster,  Nelaton,  J.  S.  Stone,  Finney, 
J.  B.  Roberts,  Lexer,  and  many  others. 

J.  Mason  Warren  of  Boston  was  probably  the  first  to  introduce  the 
successful  application  of  plastic  surgery  in  the  United  States.  T.  D. 
Mutter  and  Joseph  Pancoast  of  Philadelphia  were  also  pioneers  in  this 
work.  To  these  three  men  is  due  the  credit  of  introducing  plastic 
methods  into  American  surgery. 

Szymanowski,  a  Russian,  in  1867,  in  his  Manual  of  Operative  Surgery, 
collected  the  various  operative  procedures  for  the  relief  of  deformities 
requiring  plastic  surgery  and  attempted  to  classify  them.  The  portion 
of  the  book  devoted  to  plastic  surgery  has  yet  to  be  surpassed. 

The  use  of  the  pedunculated  flap  of  skin  and  subcutaneous  fat, 
based  on  the  Indian  or  the  Italian  method,  applied  to  the  fresh  or 
granulating  wound,  gradually  became  more  common.  Especially  for 
the  relief  of  contractures  and  in  locations  exposed  to  pressure  and 
friction. 

The  transplantation  of  a  pedunculated  flap  by  successive  migration 
was  probably  first  employed  by  Ph.-J.  Roux  in  supplying  lost  por- 
tions of  the  cheeks;  the  flap  was  taken  from  the  thigh  of  the  patient 
(Pancoast) . 

Blandin  reported  a  case  in  which  a  part  of  the  upper  lip  and  a  part 
of  the  cheek  and  ala  of  the  nose  had  been  destroyed.  He  raised  a  flap 
from  the  lower  lip,  attached  it  to  the  upper  lip  and  then  transferred  it 
successfully  to  the  cheek  and  nose. 

The  first  report  of  the  use  of  a  pedunculated  flap  from  adjacent 
tissue  by  an  American  surgeon,  is  that  of  J.  Mason  Warren  of  Boston 
in  1837.  He  was  successful  in  constructing  a  nose  by  the  Indian  method 
with  a  pedunculated  flap  from  the  forehead.  T.  D.  Mutter  of  Phila- 
delphia, in  1842,  reported  three  cases  in  which  he  successfully  shifted 
large  pedunculated  flaps  of  skin  and  subcutaneous  fat  from  the  shoulder 


HISTORICAL   REVIEW  5 

and  deltoid  region,  to  till  defects  left  by  relieving  contractures  of  the 
neck  and  chin  following  burns. 

Joseph  Pancoast  of  Philadelphia,  in  1842,  reported  the  successful 
use  of  pedunculated  flaps  from  the  cheeks,  forehead  and  upper  lip. 

Frank  H.  Hamilton,  on  January  21,  1854,  in  the  Buffalo  General 
Hospital,  raised  a  pedunculated  flap  of  skin  and  subcutaneous  fat 
10.X17.5  cm.  (4X7  inches),  from  the  calf  of  a  man's  leg  for  the  relief 
of  a  large  traumatic  ulcer  of  the  other  leg.  This  flap  was  held  away 
from  its  bed  with  dressings  and  remained  viable,  although  there  was  a 
considerable  degree  of  shrinkage.  After  two  weeks  he  freshened  the 
under  surface  and  edges  of  the  flap,  excised  the  ulcer  and  part  of  the 
cicatrix,  then  partly  covered  the  wound  with  the  flap  and  secured  the 
legs  together.  Two  weeks  later  the  flap  was  amputated  from  its  base, 
but  a  portion  of  it  subsequently  sloughed.  It  is  interesting  to  know 
that,  ten  years  before  this  operation  was  performed,  Hamilton  had 
suggested  this  procedure  for  the  relief  of  an  ulcer  of  the  thigh,  but  had 
been  unable  to  obtain  the  patient's  consent.  He  recognized  the  impor- 
tant fact  that  if  a  graft  is  smaller  than  the  chasm  which  it  is  intended  to 
fill,  it  will  grow  or  project  from  itself  new  skin  to  supply  the  deficiency, 
and  hence  that  it  is  not  necessary  to  make  the  graft  as  large  as  the 
defect  to  be  covered.  No  wide  interest,  however,  was  evoked  by 
Hamilton's  report. 

After  this  there  were  reports  on  the  subject  from  the  United  States, 
England,  France  and  Germany,  but  it  was  not  until  the  work  of  Maas, 
1884-86.  that  widespread  attention  was  given  to  the  use  of  pedun- 
culated flaps.  His  papers  were  so  convincing  that  a  new  impetus  was 
given  to  the  method.  Since  his  death  there  has  been  much  work 
done  on  these  lines  by  many  surgeons,  and  splendid  results  have  been 
reported. 

The  original  Indian  and  Italian  methods  have  been  modified  from 
time  to  time,  but  their  basic  principles  are  unchanged. 

THE  DEVELOPMENT  OF  SKIN  TRANSPLANTATION 

In  1804.  Baronio,  the  physiologist,  did  the  following  experiments, 
which  he  carried  out  on  sheep: 

In  the  first  experiment,  two  whole-thickness  pieces  of  skin  of  equal 
size  and  exclusive  of  the  subcutaneous  tissue,  were  cut  from  either  side 
of  the  root  of  the  .tail  of  a  sheep,  and  were  immediately  transferred  to 
opposite  sides.     The  second  experiment  was  similar,  except  that  the 


6  PLASTIC    SURGERY 

pieces  of  skin  were  kept  detached  for  i8  minutes.  In  the  third  experi- 
ment larger  pieces  were  used,  12.5X7.5  cm.  (5X3  inches)  including  the 
cellular  tissue  and  a  bit  of  muscle.  These  were  left  detached  for  one 
hour  before  being  transferred  to  opposite  sides.  All  of  the  above- 
mentioned  experiments  were  successful,  and  the  grafts  bled  when  cut 
into  10  to  12  days  after  the  transplantation. 

J.  Mason  Warren  in  1843,  i^sed  a  successful  free  graft  of  whole  thick- 
ness skin  from  the  arm,  to  repair  a  defect  on  the  ala  following  a  rhino- 
plastic  operation  by  the  Italian  method. 

Netohtski,  on  April  11,  1869,  successfully  transplanted  small 
elliptic  shaped  pieces  of  whole-thickness  skin  from  the  back  of  the 
patient's  hand,  in  the  treatment  of  a  case  of  avulsion  of  the  scalp. 

The  hastening  of  the  healing  of  granulating  wounds  by  the  use  of 
small  detached  bits  of  skin  was  first  demonstrated  by  J.-L.  Reverdin. 
His  report  was  made  to  the  Societe  Imperiale  de  Chirurgie,  December 
8,  1869.  He  showed  a  patient  on  whom  he  had  successfully  practised 
"epidermic  grafting,"  and  described  the  grafts  as  consisting  of  epider- 
mis only.  He  says  "I  raised  with  the  point  of  a  lancet  two  little  flaps 
of  epidermis  from  the  right  arm,  taking  care  not  to  cut  the  dermis." 
These  he  appUed  to  the  granulating  surface.  He  obtained  his  idea  by 
observing  the  epithelial  growth  from  a  spontaneous  island  in  an  ulcer 
case.  Reverdin's  paper  was  discussed  on  December  15,  1869,  but  the 
importance  of  his  method  was  not  appreciated.  He  held  that  the 
living  epidermis  alone  was  necessary  for  the  success  of  the  graft,  and 
that  the  transplanted  epidermis  caused  the  transformation  of  the  em- 
bryonal cells  of  the  granulation  tissue  into  epidermic  cells.  Bryant, 
on  the  other  hand,  subsequently  declared  that  the  grafts  themselves 
grew,  and  that  there  was  a  spread  of  epithelium  from  the  graft,  and 
this  view  has  been  proved  correct,  as  it  is  now  a  well-known  fact  that 
epithelium  is  only  derived  from  preexisting  epithelium. 

Pollock  of  London,  heard  of  Reverdin's  method  in  May,  1870. 
After  trying  it  on  several  chronic  cases  he  was  very  much  impressed  with 
his  results  and  the  method  was  immediately  taken  up  by  numerous 
surgeons  in  England,  Scotland  and  Ireland.  It  soon  became  known  in 
America,  and  in  1870-71  successful  cases  were  reported  by  Frank 
Hamilton  of  New  York,  Chisholm  of  Baltimore,  Coolidge  of  Boston, 
and  others. 

In  his  exhaustive  paper  on  the  subject  published  in  1872,  Reverdin 
says  in  part:  "The  title  'epidermic  grafts'  is  not  perfectly  correct, 
as  the  transplanted  bit  is  composed  of  the  whole  epidermis  and  a  very 


HISTORICAL    REVIEW  7 

little  of  the  dermis."  He  said  that  if  the  epidermis  alone  could  be 
transplanted,  the  same  result  would  be  obtained  as  when  a  part  of  the 
dermis  was  included. 

It  is  interesting  to  note  that  Reverdin  developed  his  method  of 
grafting  before  the  introduction  of  antisepsis  and  asepsis  in  surgery, 
and  that  it  is  probably  the  only  type  of  graft  which  could  have  given 
satisfactory  results  under  such  conditions. 

The  results  obtained  by  the  method  of  Reverdin  were  not  all  that 
had  been  anticipated,  and  although  the  healing  was  hastened,  it  was 
found,  especially  in  the  region  of  joints,  that  this  method  of  grafting 
did  not  prevent  contractures.  This  fact  stimulated  investigation  and 
Oilier  of  Lyon  in  1872  grafted  much  larger  areas  of  skin,  4.,  6.  and  8. 
cm.  square  (1^5;  2%,  3I5  inches)  in  extent,  using  the  entire  epi- 
dermis with  a  portion  of  the  dermis,  instead  of  the  small  bits  of 
epidermis  0.3  to  0.4  cm.  square  {y^  to  ^f  g  inch)  as  advised  by  Reverdin. 
His  idea  was  not  to  create  multiple  centers  of  epidermization,  but  to 
substitute  for  the  ordinary  healing  a  surface  having  the  essential  ele- 
ments of  the  normal  skin  surrounding  it.  This  conception  represented 
a  distinct  advance  and  formed  the  essential  foundation  of  the  method 
later  elaborated  by  Thiersch.  Ollier's  work  was  ignored  by  his  country- 
men, as  Reverdin's  had  been. 

Thiersch,  in  1874,  transplanted  whole  thickness  pieces  of  skin  i. 
cm.  {%  inch)  in  diameter,  from  which  the  adipose  tissue  had  been 
carefully  removed.  He  laid  great  stress  upon  the  following  facts: 
that  upon  perpendicular  sections  of  the  granulation  tissue  one  can 
easily  distinguish  upon  the  deeper  part  quite  dense  connective  tissue, 
and  a  vascular  network  in  a  horizontal  position.  From  this  horizontal 
vessel  and  tissue  layer  sprouts  the  much  softer  and  more  vascular 
true  granulation  tissue,  ^^granulation  caruncle.'^  and  that  unless  we 
render  it  possible  for  this  soft  vascular  "granulation  caruncle"  to 
change  into  a  firm  cicatrix,  then  the  graft  over  it  will  sooner  or  later 
break  down ;  hence  (he  argued)  that  nothing  remains  but  to  exclude  the 
superficial  part  of  the  granulations  from  the  procedure,  and  to  graft  the 
skin  immediately  upon  the  lower  horizontal  ground.  This  idea  has 
been  proved  fallacious. 

Thiersch  held  that  the  agglutination  took  place  within  a  layer  of 
subcutaneous  cement  substance;  that  the  agglutination,  if  entirely 
successful,  resulted  from  the  inosculation  of  the  vessels  which  could  be 
seen  in  18  hours,  in  other  words,  the  connection  between  the  vessels 
of  the  granulation  tissue  and  the  applied  skin  took  place  through  inter- 


8  PLASTIC    SURGERY 

cellular  ducts,  which  filled  it  immediately  with  blood  from  the  granula- 
tion vessels,  and  that  this  blood  then  circulated  in  the  vessels  of  the 
applied  skin.  Moreover,  he  held,  that  the  vessels  of  the  transplanted 
skin  were  liable  to  a  secondary  change  in  which  their  structure 
approached,  for  a  while,  more  or  less  that  of  the  granulation  vessels. 

In  1886  Thiersch  read  the  report  of  his  perfected  method  of  skin 
grafting  at  the  Fifteenth  Congress  of  the  German  Surgical  Association. 
He  showed  that  the  healing  of  wounds  of  any  size  could  be  brought 
about  more  quickly  by  covering  the  defects  with  large  films  of  epidermis 
together  with  a  portion  of  the  dermis:  These  films  were  shaved  off 
and  placed  so  as  to  entirely  cover  the  wounds  from  which  granulation 
tissue  six  weeks  old  had  been  removed. 

The  method  became  widely  known  as  Thiersch  grafting,  no  credit 
being  given  to  the  priority  of  Ollier's  work.  In  all  justice  the  proper 
title  should  be  the  Ollier-Thiersch  method.  These  large  grafts  com- 
pletely superseded  the  smaller  grafts  recommended  by  Reverdin, 
and  his  method  was  almost  forgotten. 

W.  S.  Halsted  early  in  1890  showed  a  case  before  the  Johns  Hopkins 
Hospital  Medical  Society  in  which  a  leg  ulcer,  20.X12.  cm.  (8X4^ 
inches)  and  of  14  years'  duration,  had  been  successfully  grafted  with 
Ollier-Thiersch  grafts.  He  said  that  Thiersch  scraped  the  ulcer  and 
planted  his  grafts  on  the  scraped  and  necessarily  infected  surface. 
The  surface  being  infected,  it  was  necessary  for  the  dressing  to  be 
changed  every  day  for  about  one  week.  Dr.  Halsted's  method  was  to 
cauterize  the  ulcer  thoroughly  with  pure  carbolic  acid  and  then  excise 
it,  taking  care  not  to  infect  the  fresh  surface  thus  made,  and  then  plant 
the  grafts  on  this  fresh  aseptic  surface  after  which  the  dressings  need 
not  be  changed  for  at  least  one  week. 

The  excision  of  the  base  of  scar  tissue  and  planting  grafts  on  healthy 
clean  tissue  was  a  marked  advance. 

The  Ollier-Thiersch  method  did  not  fulfil  all  expectations.  Con- 
tractures took  place  under  grafts  of  this  type  and  there  was  little  resist- 
ance to  mechanical  insults.  Hence  surgeons  were  constantly  trying  to 
find  some  method  by  which  soft,  elastic,  resistant  healing  could  be 
obtained. 

Going  back  to  earlier  investigators  we  find  that  Lawson  in  London, 
in  1 87 1,  had  used  successfully  for  the  relief  of  ectropion  a  large  thick 
Reverdin  graft  of  the  whole  thickness  of  the  skin,  free  from  fat.  Le- 
Fort  in  France  in  February,  1872,  successfully  transplanted  from  the 
arm  for  the  relief  of  ectropion  a  free  graft  from  which  the  subcutaneous 


HISTORICAL   REVIEW  9 

fat  had  been  removed.  Good  results  were  also  obtained  by  several 
other  men  about  this  time. 

In  1875,  Wolfe  of  Glasgow,  reported  a  successful  plastic  operation 
for  the  repair  of  a  defect  about  the  lower  eyelid,  with  a  free  whole 
thickness  graft  from  the  arm,  measuring  2.5X5.  cm.  (1X2  inches), 
from  which  all  the  subcutaneous  fat  had  been  removed.  He  is  gener- 
ally accredited  with  introducing  this  method,  and  with  insisting  on  the 
complete  removal  of  the  subcutaneous  fat.  although  Lawson,  in  1871, 
and  LeFort,  in  1872,  had  done  practically  the  same  thing.  At  any 
rate  to  Wolfe  is  due  the  credit  of  estabhshing  the  method  in  ophthalmic 
practice. 

Esmarch  and  others  used  the  method  with  success,  but  to  Krause 
of  Altona  is  due  the  credit  of  introducing  it  into  general  surgery.  The 
method  should  be  called  the  Wolfe-Krause  method. 

Krause  reported  his  perfected  technic  at  the  Twenty-second  Con- 
gress of  the  German  Surgical  Association,  and  advised  the  use  of  the 
whole-thickness  graft  for  all  purposes  where  the  Ollier-Thiersch  graft 
had  been  found  lacking.  He  reported  21  cases,  and  found  that  skin 
from  any  location  could  be  used  after  the  removal  of  the  subcutaneous 
fat. 

Hirschberg,  at  the  afternoon  meeting  of  the  same  day  claimed 
priority  for  the  use  of  whole-thickness  skin  grafts  with  subcutaneous 
fat.  He  said  that  hyperemia  should  be  induced  before  excising  the 
graft  with  the  fat  and  that  this  might  be  accomplished  by  beating  the 
part  with  a  piece  of  rubber  tubing,  thus  repeating  to  a  certain  extent 
the  old  Indian  method.  He  also  thought  that  only  skin  with  a  very 
dense  vascular  network  should  be  used.  Krause  opposed  these  ideas 
of  Hirschberg,  and  further  investigation  has  proved  that  there  is  no 
advantage  in  hyperemia  and  that  there  is  a  distinct  disadvantage  in  the 
presence  of  fat. 

The  Wolfe-Krause  method  was  used  in  suitable  cases  for  some  time, 
but  the  larger  operative  procedure  as  compared  with  the  Ollier-Thiersch 
method  discouraged  its  general  use. 

In  1905  Young  of  Glasgow,  suggested  various  modifications  of 
Krause's  technic. 

In  this  brief  historical  review  of  the  subject  I  have  endeavored  to 
touch  only  upon  the  main  features  in  the  development  of  plastic  surgery. 
Many  names  famous  in  plastic  surgery  have  been  omitted,  but  I 
shall  endeavor  in  the  pages  that  follow  to  give  these  names  prominence 
in  the  chapters  in  which  their  particular  work  is  considered. 


10  PLASTIC    SURGERY 


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Galex.     "Opera  X.  Leoniceno  iterprete."  Paris,  15 14. 
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H.\iiiLT0N,  F.  H.     "N.  Y.  Jour,  of  Med.,"  Sept.,  1854,  165. 

JoBERT,  A. -J.     "Traite  de  Chirurgie  Plastique."     Paris,  1849. 

JoHxsTOX,  Christopher.  "Ashhurst's  Internat.  Encyclopedia  of  Surgery,"  vol.  i, 
1881,531. 

Keegax.     "  Rhinoplastic     Operations,"     1900. 

V.  L.\XGENBECK,  B.  R.  C.  "Weitere  Erfahrungen  im  Gebiete  der  Uranoplastik  Mittelst 
Ablosung  des  Mucosperiostalen  Gaumeniiberzuges."  170  pp.,  8vo.  Berlin.  A. 
Hirschwald,  1863. 


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"Berl.  klin.  Wchnschr,"  1865,  xv. 

"New  York  Med.  Jour,"  187S,  xxvii. 
Larrey,  de  D.  J.     "Memoires  de  Chirurgie  Militaire  et  Campagnes."     Paris,  1812. 
LiSTOX.     "Elements  of  Surgery.''     London,  1831. 

"Practical  Surgery."     London,  1837. 

Mutter,  T.  D.     "'Amer.  Jour.  Med.  Science,"  vol.  20,  1837,  341. 
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Paxco.\st,  J.     "Amer.  Jour.  Med.  Science,"  n.  s,  vol.  4,  1842,  337. 
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"Med.  Times  &  Gaz."     1870,  ii,  502. 

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1721,  29. 
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Velpeau,  Aif.  a.  L.  M.     "New  Elements  of  Operative  Surgery."     Washington,  1835. 

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CHAPTER  II 
GENERAL  CONSIDERATIONS 

The  utilization  of  those  skilled  in  well-established  medical  and  surg- 
ical specialties  in  the  care  of  sick  and  wounded  soldiers,  has  been 
successfully  demonstrated  to  the  medical  organizations  of  the  various 
armies  for  the  first  time  during  the  present  great  world  war. 

In  the  Medical  Corps  of  our  own  Army  in  all  previous  wars,  and 
even  up  to  the  last  two  years,  specialties  were  not  recognized  as  such, 
and  an  officer  of  the  Medical  Corps  whether  professionally  equipped 
or  not,  was  too  often  assigned  to  take  care  of  cases  requiring  the  atten- 
tion of  a  highly  trained  specialist.  To  my  mind  the  recognition  of  the 
specialist  in  the  Medical  Corps  of  the  Army  is  a  great  step  forward,  as 
it  insures  the  soldier  the  best  care  in  every  kind  of  injury  or  illness. 

For  many  years  as  I  have  become  more  and  more  familiar  with 
the  intricacies  of  plastic  surgery,  I  have  urged,  in  spite  of  much  oppo- 
sition, that  this  be  made  a  surgical  speciahty,  and  the  war  has  demon- 
strated beyond  a  doubt  the  need  of  this  as  a  special  branch.  ^ 

There  are  large  hospitals  in  all  the  warring  countries  devoted  entirely 
to  plastic  surgery  of  the  face,  and  in  our  own  organization,  under  the 
Section  of  Surgery  of  the  Head,  there  is  a  subdivision  of  Facial  Plastic 
and  Oral  Surgery,  to  deal  with  reconstructive  work  on  the  face.  This 
is  all  very  well  as  far  as  it  goes,  but  it  must  be  understood  that  recon- 
structive work  on  the  face,  although  vitally  important,  is  only  a  part 
of  plastic  surgery,  and  that  plastic  and  reconstructive  work  is  as  neces- 
sary and  is  just  as  important  on  other  parts  of  the  body. 

Except  for  the  vastly  greater  number  of  cases  and  the  greater  preva- 
lence of  injuries  and  destruction  of  the  bony  framework,  the  real  plastic 
and  reconstructive  work  on  war  wounds  differs  not  a  great  deal  from 
that  done  in  civil  practice. 

By  plastic  and  reconstructive  surgery  is  meant  that  branch  of 
surgery  which  deals  with  the  repair  of  defects  and  malformations, 
whether  congenital  or  acquired,  and  with  the  restoration  of  function  and 
the  improvement  of  appearance.  This  is  accomplished  chiefly  by  the 
transfer  of  tissue,  either  from  the  immediate  neighborhood,  or  from  some 

1  Davis,  J.  S.:  Jour.  Amer.  Med.  Assn.,  July  29,  1916,  p.  338. 

12 


GENERAL    CONSIDERATIONS  1 3 

distant  part.  The  deformities  dealt  with  in  plastic  surgery  for  the  most 
part  involve  the  skin  or  adjacent  soft  parts,  rather  than  the  bones  and 
joints,  the  ligaments  or  tendons.  The  treatment  of  large  denuded 
surfaces,  requiring  skin  grafting,  and  of  intractable  surface  wounds, 
should  also  come  under  the  care  of  the  plastic  surgeon. 

It  is  imperative  that  the  surgeon  who  expects  to  do  plastic  and 
reconstructive  work  should  have  had  a  thorough  general  surgical  train- 
ing before  attempting  to  specialize  in  this  branch.  Above  all  he  must 
know,  and  thoroughly  appreciate  the  principles  governing  the  healing 
of  tissues  and  the  repair  of  wounds.  A  special  knowledge  of  the  resist- 
ance and  utiUty  of  tissues  more  or  less  infiltrated  with  scar  tissue  is 
also  necessary,  because  in  many  instances  normal  tissue  is  unavailable. 
A  knowledge  of  the  surgical  handling  of  children  is  also  very  important 
in  civil  practice. 

In  reconstructive  surgery  of  the  jaws  and  palate,  the  plastic  surgeon 
should  have  the  constant  advice  and  cooperation  of  a  skilled  dental  and 
oral  surgeon.  This  combination  has  proved  to  be  of  inestimable  value 
in  France  and  England,  and  also  in  Germany,  where  those  of  the 
wounded  w^ho  require  reconstructive  work  on  the  face  are  concentrated 
in  special  hospitals. 

In  choosing  an  operation  for  the'repair  of  a  defect  on  the  face  or  other 
exposed  portions  of  the  body,  care  must  be  taken  that  the  scar  left  by 
shifting  the  flap  used  for  this  repair  does  not  cause  the  patient  as 
much  concern  as  the  original  defect. 

My  experience  has  been  that  we  seldom,  if  ever,  find  two  plastic 
cases  exactly  ahke,  and  that  no  cut  and  dried  methods  can  be  employed. 
Each  case  should  be  carefully  studied,  and  the  various  methods  of 
repair  considered  from  every  standpoint.  This  endless  variety  in 
itself  brings  a  certain  fascination  to  the  operative  treatment  and  to  the 
after-care  of  these  patients.  Sound  surgical  judgment  is  often  neces- 
sary to  determine  what  should  be  done;  whether  or  not  a  plastic  pro- 
cedure should  be  finished  at  one  operation;  how  far  to  go  in  the  initial 
operation,  and  when  to  follow  with  the  secondary  procedures.  The 
results  in  certain  groups  of  cases  are  very  slow,  and  in  these  the  process 
is  one  of  gradual  building  up.  In  such  cases  the  entire  series  of  opera- 
tions should  be  planned  with  regard  to  the  ultimate  result  and  not  to 
the  immediate  relief  of  the  condition.  The  post-operative  treatment 
and  dressings  should  be  done  by  the  surgeon  himself  or  directly  under 
his  eye,  because  successful  results  in  a  great  measure  depend  on  skillful 
and  judicious  after-treatment. 


14  PLASTIC    SURGERY 

The  simpler  the  operation  the  more  likely  it  is  to  succeed,  and  this 
is  especially  exemplified  in  the  operations  for  the  relief  of  harelip.  It 
is  wise  to  make  haste  slowly  in  plastic  surgery,  and  to  underdo  rather 
than  overdo.  A 

The  plastic  surgeon,  with  his  special  knowledge  of  tissue  trans- 
plantation, can  be  of  great  use  to  the  general  surgeon,  and  to  the 
orthopedist  in  dealing  with  scars  and  in  repairing  the  defects  left  by 
certain  necessarily  mutilating  operations.  This  applies  also  to  the 
gynecologist,  and  genito-urinary  surgeon,  when  their  patients  require 
more  extensive  transplantations  than  these  specialists  are  accustomed 
to  undertake. 

Plastic  surgery  cannot  be  done  in  a  hurry,  either  in  the  operative 
steps  in  the  process  or  in  the  length  of  time  required  to  complete  the 
final  operation.  Frequently  in  complicated  cases  single  operations 
require  several  hours  to  complete,  on  account  of  the  great  detail  neces- 
sary and  the  difficulties  encountered  in  carrying  out  the  work.  Some- 
times the  patient  may  be  in  the  hospital  for  months  (combating 
infection) ,  before  he  is  even  ready  for  operation,  and  then  be  obliged 
to  undergo  several  major  operations  with  interspersed  minor  procedures. 
Ten,  tw^enty,  and  even  more  operations  may  be  necessary  to  accomplish 
the  desired  result,  and  thus  it  can  readily  be  seen  that  this  work  is  a  i 
tremendous  tax  on  both  patient  and  surgeon.  Fortunately,  the 
majority  of  the  patients  requiring  these  operations  are  endowed  withj 
extraordinary  fortitude,  and  occasionally  the  surgeon  is  found  who] 
is  able  to  give  his  interested  attention  to  this  work. 

Thorough  familiarity  with  the  free  transplantation  of  skin,  fat, 
fascia,  bone  and  cartilage,  is  essential,  as  all  of  these  tissues  are  con- 
stantly utilized  in  reconstructive  work.  The  principles  of  tissue  shift- 
ing and  of  the  use  of  pedunculated  flaps  must  be  understood,  and  also 
the  possibilities  of  combinations  with  the  above-mentioned  free 
transplants. 

For  all  sorts  of  plastic  operations  it  is  desirable  that  the  patient  ■ 
should  be  in  the  best  possible  physical  condition,  and  no  plastic  opera-  : 
tion  should  be  undertaken  on  those  still  suffering  from  active  local 
disease.  A  complete  physical  examination  should  be  made  of  eachj 
case  before  operation,  and  in  children  the  urine  should  be  examined] 
with  special  reference  to  the  presence  of  acetone  and  diacetic  acid. 
Low  hemoglobin  contraindicates  operation  on  the  ordinary  case,  and 
I  seldom  care  to  operate  when  the  percentage  is  below  75.     If  there  is 


GENERAL   CONSIDERATIONS  1 5 

bronchial  irritation,  or  rise  of  temperature  at  the  time  selected  for  opera- 
tion, it  is  safer  to  defer  the  work. 

Asepsis  rather  than  antisepsis  should  be  maintained  throughout 
the  operation,  and  during  convalescence,  since  infection  is  one  of  the 
chief  causes  of  failure.  It  goes  without  saying  that  rubber  gloves 
should  be  worn  by  the  operator  and  all  assistants. 

The  tissues  should  be  treated  with  the  greatest  consideration.  Keen- 
cutting  instruments  must  be  used  to  avoid  unnecessary  bruising  of  the 
tissues.  The  flaps  should  be  handled  with  special  forceps,  or  small 
sharp  hooks  (Fig.  i).  The  area  into  which  the  flap  or  graft  is  to  be 
transferred  should  be  perfectly  dry,  and  all  hemorrhage  checked,  in  as 
much  as  many  failures  are  due  to  a  blood  clot  forming  beneath  the 
transplant,  which  prevents  the  early  acquisition  of  a  new  blood  supply. 


FULL  SIZE  END 


P> 


FULL  6IZE  END 


Pig.    I. — Single  and  double  sharp  hooks  for  handling  flaps. 

If  possible,  all  scar  tissue,  deep  or  superficial,  should  be  removed.  An 
accurate  estimate  of  immediate  and  subsequent  tissue  shrinkage  must 
be  planned  for.  Accurate  apposition  of  the  skin  edges  is  desirable,  as 
prompt  healing  minimizes  scar  tissue. 

One  of  the  most  important  points  in  plastic  surgery  when  tissue 
of  any  kind  is  transplanted,  is  that  there  be  7io  tension  either  on  the 
flaps,  or  on  free  grafts.  Always  remove  a  suture  if  it  blanches  the  tissue, 
or  causes  too  much  tension.  I  like  to  see  a  surgeon  who,  when  doing  plastic 
work  does  not  hesitate,  in  spite  of  his  audience,  to  take  out  sutures  which 
are  too  tight  or  which  have  not  been  placed  exactly  to  suit  him. 

As  a  rule  prosthesis  should  be  avoided,  as  it  is  rare  in  plastic  surgery 
that  we  encounter  a  deformity  which  cannot  be  helped  by  logical  surg- 
ical methods.  At  best  the  surgeon  can  accomplish  only  a  certain 
amount,  nature  (when  obstacles  are  removed)  being  relied  on  to  com- 
plete his  work. 

To  sum  up  the  matter,  in  the  words  of  Sir  Frederick   Treves,^ 

"No  branch  of  operative  surgery  demands  more  ingenuity,  more  patience, 
more  forethought,  or  more  attention  to  detail." 

•1  Treves,  Sir  Frederick:  Manual  of  Operative  Surgery,  ii,  p.  104. 


1 6  PLASTIC    SURGERY 


DEFIXITIOX  OF  TERMS 


In  this  work  the  following  definitions  will  be  used.  By  a  flap  we 
mean  a  mass  of  tissue  attached  at  some  portion  of  its  margin  or  its 
base  by  a  pedicle  through  which  it  receives  its  blood  supply,  and  which 
can  be  shifted  at  once,  or  subsequently,  as  far  as  the  pedicle  will  allow. 

By  a  graft  we  mean  a  mass  of  tissue  which  is  cut  free  to  be  trans- 
planted wherever  necessary.  An  autograft,  is  a  graft  obtained  from 
the  same  individual;  an  isograft,  is  obtained  from  another  individual 
but  of  the  same  species;  a  zoograft,  is  obtained  from  a  lower  species. 

The  term  take  means  that  the  entire  graft  has  been  successfully 
transplanted  and  has  healed  in  its  new  bed.  A  partial  take  means  that 
only  a  portion  of  the  graft  has  been  successfully  transplanted. 

METHODS  OF  CLOSIXG  DEFECTS 

A  surface  defect  which  cannot  be  closed  by  simple  suturing,  may  be 
closed  in  one  of  four  ways:  (i)  By  skin  grafting;  (2)  By  the  French 
method,  that  is.  by  gliding  the  edges  together  and  suturing.  This  method 
was  originally  devised  by  Celsus,  but  has  been  especially  developed  by 
the  French.  Where  there  is  tension  the  skin  may  be  mobilized  to  a 
great  extent  by  undercutting,  and  in  this  way  large  areas  of  skin  may 
be  shifted  without  impairing  the  vitaUty.  (3)  By  the  Indian  method, 
that  is,  by  using  pedunculated  flaps  from  tissue  in  the  immediate 
neighborhood  with  more  or  less  torsion  of  the  pedicle.  This  method 
has  its  limitations,  as  in  some  instances  healthy  flaps  from  adja- 
cent tissue  are  impossible  to  obtain  especially  where  a  defect  is  situated 
in  the  midst  of  scar  tissue.  (4)  By  the  Italian  or  Tagliacotian  method 
by  using  pedunculated  flaps  from  distant  parts.  This  may  be  accom- 
plished by  a  single  or  double  transfer.  It  is  as  a  rule  easy  to  secure 
sufficient  tissue  with  flaps  from  distant  parts,  but  the  constrained 
position  necessary  in  order  to  utilize  these  flaps  is  very  irksome  to  the 
patient,  and  many  are  unwilling  or  are  physically  unable  to  endure  the 
discomfort. 

PLASTIC  OPERATIONS  FOR  CLOSING  DEFECTS  OF  VARIOUS 

SHAPES 

In  making  a  defect  which  will  later  have  to  be  closed  by  plastic 
operation,  it  is  desirable  that  the  contour  of  the  defect  should  be  as 
simple  and  as  regular  as  possible. 


GENERAL   CONSIDERATIONS 


17 


The  simplest  method  of  closing  defects  of  moderate  size  is  by  approxi- 
mation of  the  edges.  In  order  to  accomplish  this  it  may  be  necessary 
to  undercut  the  skin,  and  if  this  does  not  give  sufficient  relaxation  then 
liberating  incisions  should  be  made. 

The  concavity  of  the  semilunar,  or  broad  V-shaped  relaxation 
incisions  should  be  toward  the  defect,  and  the  incision  should  be  only 
through  the  cutis.  Relaxation  incisions  may  be  made  on  one  or  both 
sides,  as  may  be  necessary.  The  defects  left  by  the  relaxation  incisions 
may  either  be  skin  grafted  or  allowed  to  granulate. 


<: 

^A-:' 

;^:^•■:^> 

B 

E 

A 

i 

^ 

■4: 

C 

r 

^ 

A' 

B 

C 

/m 

y^ 

D 

^ 

A-«=r^ 

"y^^"^ 

c  I  Jt?l  I  UeL  i '' 


^l  M  k  -1  i*^ 


A  T  1    r  1 


B 


Fig.  2. — Plastic  operations  for  closing 
small  [defects  by  undercutting  and  approxi- 
mating the  skin  edges.  {Esmarch  and  Kowal- 
zig.) 


Fig.  3. — Method  of  coapt- 
ing  the  angle  of  a  wound. 
The  dotted  area  shows  the  por- 
tion undermined.     (Moorhead.) 


Defects  of  various  shapes  may  be  closed  by  means  of  pedunculated 
flaps  from  the  adjacent  skin.  This  method  is  applicable  for  the  closure 
of  much  larger  defects  than  can  be  closed  by  undercutting  and  sliding. 

The  following  figures  2  to  43  which  explain  themselves,  will  give  a 
few  suggestions  as  to  the  various  plastic  methods  which  may  be  utilized 
in  closing  defects  of  different  shapes,  and  may  be  modified  to  suit 
conditions. 

Preparation  of  the  Part  from  which  the  Graft  or  Flap  is  to  be 
Taken. — Two  methods  of  cleansing  the  skin  have  been  found  service- 
able in  my  work,  (i)  Shave  the  part  selected,  then  scrub  carefully 
with  green  soap  and  water ;  rinse  with  sterile  water ;  sponge  with  ether 
followed  by  alcohol;  then  rinse  with  sterile  normal  salt  solution.  This 
method  is  seldom  used  on  the  face.  Elsewhere  on  an  unbroken  surface 
it  is  without  doubt  most  dependable,  but  is  slow  of  execution,  is 
sloppy,  and  is  more  or  less  disagreeable  to  the  patient. 


PLASTIC    SURGERY 


Plastic  closure  of  defects  of  various  shapes  by  undercutting  and  sliding. 


5^     '      'c'l!£ 


^^K 


rrr— * — E 


^  I  ^Xi  I  y ' 


Fig.  4. — Lisfranc's  method. 
(Szymanowski.) 


Fig.    5. — Szymanowski' s  method. 


K        I 


K         I 


1^-    N        -*- 


■i      '        ^ 


T  H--G    P. 


B 
A   E+F 

■*-^H — r 


■+— N 


Fig.   6. — Cole's  method. 

Af— Ic 


B 


E       A|^T     T 1 V-^ 


;g  D  *v 

Fig.    7. — Szymanowski's  raethod. 
^        E.  A  p CA    E-;— + 


•F      B^V. 


1-     k    Jl-F 


H 

Fig.  8.  Fig.  9. 

Figs.  8  and  c. — Szymanowski's  method. 


Fig.   10. — Jasche's  method.       Fig.   ii.  Fig.   12. 

(Szymanowski.)  Figs,    ii  and  12. — Szvmanowski's  method. 


G/^ 


C  K  "5  C 

Fig.    13. — Szymanowski's  method. 

B  A C  D         „        y   yAC^ 


Fig.    14. — Szymanowski's  method. 


GENERAL    CONSIDERATIONS 


19 


(2)  After  a  dry  shave  paint  the  part  with  2)^  per  cent  tincture  of 
iodin  (the  U.S. P.  tincture  being  7  per  cent)  two  or  three  coats,  either 
on  the  dry  skin  or  after  sponging  it  with  benzine  or  ether.     This  is  a 

Plastic  operations  for  closing  defects  by  undercutting  and  slicing.     Showing  the 
types  of  relaxation  incisipons. 


Fig.   15. — Method  of  Celsus. 
(Szymanou'ski.) 


A     C 


A      C 


f;o 


»-■= 


BE  BE 

Fig.   16. — Dieffenbach's  method. 
(Szymanowski.) 


Fig.    17.— Guerin's  method. 
(Szymanowski.) 


•  E 


MSP -F 


Fig.    18. — Dieffenbach's  method. 
(Szymanowski.) 


G 

-  F    \/ 

—  </  M 
....£     /N 

r 

Fig.    19. — Szymanowski. 


V3 


I         I  I  £ 


1 


G 

Fig.   20. — Szymanowski. 


?:rrr^ 


.UHl^i 


AC 

t 

F     >    I     I  U    i     (       H 


Fig.   21. — Method  of  Le.xer-Bevan. 


quick  and  satisfactory  method,  and  is  especially  useful  on  the  face, 
where  scrubbing  is  impracticable. 

I  do  not  believe  that  stronger  solutions  of  iodin  should  be  used 
in  this  work,  unless  the  excess  is  immediatelv  washed  oft"  with  alcohol. 


k 


20 


PLASTIC    SURGERY 


The  disadvantage  of  iodin  is  the  occasional  burn  which  it  may  cause, 
and  in  a  few  cases  a  very  disagreeable  rash  may  develop  when  there  is  an 
idiosyncrasy  to  this  drug.  Strong  antiseptics  of  all  sorts,  other  than 
iodin,  are  contraindicated  on  grafts  or  flaps. 

Plastic  closure  of  circular  defects  by  the  excision  of  triangles,  with  undercutting, 
sliding  and  suture. 

.(   I    I    I    I    F 


F.  E    f    M    I   I, 


/  \ 


Fig.  22. — Szymanowskj's  method. 


H-- 


.^f 


C  D 

T 


Fig.   23. — Szymanowski's  method. 


|---n- 


.--— F 


•I    \    I 


D  E 

-Szymanowski's  miethod. 


ANESTHESIA 

Local  anesthesia  should  be  employed  whenever  possible.  This 
may  be  effected  by  infiltration  along  the  line  of  incision,  or  by  nerve 
blocking.  The  infiltration  method  as  a  rule  causes  very  little  trouble  in 
the  healing  of  the  wounds,  but  there  is  no  question  that  in  doubtful 
tissue  this  method  lowers  the  resistance  of  the  edges,  and  the  healing 
may  not  be  quite  so  satisfactory,  I  find  that  0.5  per  cent  novo- 
caine,  procaine,  or  apothesine,  with  from  5  to  10  drops  of  adrenalin 
chloride  (i-iooo)  to  30.  c.c.  ( i  ounce)  a  safe  local  anesthetic  for  general 
use,  and  for  nerve  blocking  i  per  cent  is  efficient. 

Macht  has  recently  described  the  anesthetic  properties  of  benzyl 
alcohol  (phenmethylol) ,  and  I  have  used  this  substance  with  success 
(in  infiltration  anesthesia),  in  strengths  of  from  i  to  3  per  cent  in 
normal  salt  solution,  and  in  nerve  blocking  in  a  i  per  cent  strength. 


GENERAL   CONSIDERATIONS 


21 


Method  of  closure  of  defects  (not  circular)  by  the  excision  of  small  triangles  of 
normal  skin  followed  by  undercutting,  sliding  and  suture. 


[,V.''r^^^c   D    <    r    I 1 C 

Fig.   25. — V.  Ammon's  method.      (Szymanowski.) 


'>  ^  1  iai  nsn  - 


R D 

Fig.   26. — V.  Ammon's  method.      {Szymanowski.) 


Pig.   27. — Szymano\vski"s  method. 


Fig.   28. — Burow's  method.      {Szymanowski.) 


rht 


STWjn 


c  c 

Fig.   29. — Burow's  method.      {Szymanowski.) 


0  A 


^  G  B^ 


^T^ '       '    ^  ^J 


C  £  C^  E 

Fig.   30. — Szymanowski's  method. 


22 


PLASTIC    SURGERY 


Method   of   closure    of   defects    (not   circular)    by  the   excision   of  small   triangles   of 
normal  skin  followed  by  undercutting,  sliding  and  suture,  continued. 


^ 


A V 


F 

)      r    1^/ 


;K  bL_i \ 1 i ^ 


•\ 


t 


Fig.  31. — Burow's  method.      (Szymanowski.) 

F  /^  f 

f^  \G     A 


Yr^'^ 


Fig.   32. — Burow's  method.      (Szymanowski.) 


Method  of  closing  defects  by  means  of  pedunculated  flaps  from  adjacent  skin. 

T 


Fig.   33. — Bilateral  flaps  with  one  pedicle  above  and  one  below. 


Fig.  34. — Hasner's  method.      (Szymanowski.) 


GENERAL    CONSIDERATIONS  23 

Methods  of  closing  defects  by  means  of  pedunculated  flaps  from  adjacent  skin,  continued. 


Fig.   35. — Double  bilateral  flaps  with  pedicles  above  and  below. 


Fig.   36. — Weber's  method.      (Szymanowski.) 
E    '\ 


Fig.  37. — Szymano\vski"s  method.  Fig.  38. — Szymanowski's  method. 


E  C  E 

Fig.   39. — Szymanowski's  method. 


Fig.   40. — Szymanowski's  method. 


24 


PLASTIC    SURGERY 


Methods  of  closing  defects  by  means  of  pedunculated  flaps  from  adjacent  skin,  continued. 


H-  H- 

Fig.   41. — Szymanowski's  method. 


r.- 


Fig.   42. — Letenneur's  method.      (Szymanowski.) 


o-.^ 


D  -  N      -i-  iVL  I  1 

Fig.  43. — Brun's  method.      (Szymanowski.) 

It  can  be  used  both  with  and  without  adrenahn  (5  to  10  drops  to  30. 
c.c.  (i  ounce)).  It  has  the  advantage  of  being  practically  non-toxic; 
it  is  easily  metabolized,  and  excreted  in  an  innocuous  form;  it  can  be 
sterilized  by  boiling  and  is  comparatively  inexpensive. 

General  anesthesia  must  be  used  in  many  instances.  The 
choice  of  anesthetic  must  depend  on  circumstances,  although  ether  is 
usually  to  be  preferred,  given  by  the  drop  method,  or  in  selected  cases 
by  the  intratracheal  route.  Combination  anesthesia  may  be  used  with 
advantage  in  some  long  cases;  a  portion  of  the  work  being  done  under 
local  anesthesia,  for  instance  in  securing  a  cartilage  graft,  and  the 
remainder  under  a  general  anesthetic. 

General  anesthesia  with  nitrous-oxide-oxygen,  and  ethyl  chloride, 
may  be  used  in  suitable  cases.  Where  a  general  anesthetic  is  used, 
especially  in  face  and  mouth  cases,  it  is  essential  that  the  anesthetist 
should  be  an  expert.-^ 

^  For  more  detailed  information  on  local  anesthesia,  the  reader  is  referred  to  "Local 
Anesthesia"  by  Braun  &  Shields,  1914,  and  "Local  Anesthesia,"  2d.  ed.,  1918,  by  C.  A. 
AUen. 


GENERAL   CONSIDERATIONS 


25 


Fig.  44.  Fig.  45. 

Figs.  44  and  45. — Langer's  lines  of  cleavage  of  the  skin.     {Modified  from  Kocher.) 
In  all  operations  in  which  a  narrow  inconspicuous  scar  is  an  object,  the  incision  should 
be  made  parallel  to  the  tension  lines.     If  this  is  done  there  will  be  little  gaping  of  the  wound. 
If  the  incision  is  made  across  these  lines  wide  gaping  will  occur  and  a  more   conspicuous 
scar  will  result. 


26 


PLASTIC    SURGERY 


INCISIONS  AND  METHODS  OF  CLOSURE 

The  incisions  used  in  plastic  surgery  should  as  far  as  possible  be 
made  parallel  to  the  tension  planes  of  the  skin  (Figs.  44  and  45).  In 
many  cases  curved  incisions  will  accomplish  more  than  straight  ones. 

On  the  face  the  natural  lines  should  be  followed,  and  if  this  is  not 
possible,  the  incision  should  be  made  parallel  to  these  lines  and  not 
across  them. 


ABC 
Fig.   46. — Method  of  making  slanting  incisions.      (Aymard.) 

A.  Schematic  drawing  of  usual  incision  at  right  angles  to  the  surface,  (i)  Skin. 
(2)   Subcutaneous  tissue. 

B.  Beveled  or  slanting  incision. 

C.  Position  assumed  by  edges  after  the  incision  is  made.  It  can  be  easily  seen  that 
accurate  closure  of  this  incision  is  difficult  on  account  of  the  thin  lip  of  epithelium  on  the 
overlapping  margin. 

The  incision  through  the  skin  made  at  right  angles  to  the  surface 
is  generally  used,  as  it  can  be  utilized  in  nearly  every  situation.  Ob- 
lique incisions  through  the  skin  have  been  used  for  many  years  (being 
mentioned  by  Pancoast  in  1842),  on  the  ground  that  the  resulting  scar 
will  be  less  conspicuous.  Recently  G.  L.  Aymard  has  emphasized 
this  point.     His  contention  is  theoretically  true,  but  in  my  experience 


Fig.   47. — Halsted's  subcuticular  suture. 
The  needle  does  not  penetrate  the  epithelial  surface  except  at  the  beginning  and  ending 
of  the  suture.      When  the  suture  is  of  non-absorbable  material,  such  as  silver  wire,  it  is 
advisable  to  loosen  it  in  the  tissues  as  it  is  being  inserted,  otherwise  it  may  stick  and 
break  when  an  attempt  is  made  to  remove  it. 

the  thin  overlapping  lip  of  epithelium  is  difhcult  to  approximate  ac- 
curately, and  the  result  is  not  appreciably  better  than  that  obtained 
in  a  carefully  closed  wound  made  at  right  angles  to  the  surface 
(Fig.  46J. 

When  the  edges  of  a  defect  opening  into  a  cavity,  such  as  the  mouth, 
are  thin,  and  where  paring  would  add  little  to  the  desired  thickness, 
it  is  better  to  split  the  edges ;^  then  close  with  two  layers  of  sutures,  so 

'  Duncan,  John:  Linear  Incisions  and  Everting  Sutures,  Edinburgh  Hosp.  Reports., 
Vol.   1,   1893,  P-  451- 


GENERAL    CONSIDERATIONS 


27 


placed  as  to  evert  both  the  inner  and  outer  edges.  This  may  be  done 
with  one  double  vertical  mattress  suture  which  unites  both  skin  and 
mucous  membrane,  and  will  accomplish  the  same  purpose.  This 
method  of  splitting  is  especially  useful  in  certain  harelip  cases,  where 


Fig.   48. — The  on-end  mattress  suture.      {McMillen.) 

1.  Begin  as  in  any  interrupted  suture. 

2.  Either  thread  the  other  end  of  the  suture  or  reverse  the  needle.in  the  holder  and  pass 
it  through  the  skin  very  close  to  the  margin. 

3.  The  sutures  tied  and  the  edges  slightly  everted  are  held  in  appro.ximation. 

the  margins   are   thin;    also   in   conserving  all  the  tissue  in  the  soft 
palate,  as  suggested  by  Davies-CoUey  and  H.  M.  Sherman. 

In  the  hands  of  an  expert  Halsted's  subcuticular  suture  is  the  ideal 
method  of  closing  a   skin  wound,   where  there  is  no   tension.     This 


SKIN 


MUCOOS 


A  B 

Fig.   49. — Methods  of  using  the  on-end  mattress  suture  for  the  skin  and  mucous  membrane. 

.4.   Showing  the  on-end  mattress  suture  for  everting  the  edges  of  the  mucous  membrane 
as  used  by  Blair. 

B.   The  same  stitch  applied  to  the  skin. 

suture  was  originated  as  an  interrupted  suture  tied  beneath  the  skin, 
but  it  was  soon  found  that  a  continuous  removable  skin  suture  was 
preferable  (Fig.  47). 

The  single  on  end  or  vertical  mattress  suture  described  by  McMillen 


28 


PLASTIC    SURGERY 


for  the  skin  (Fig.  48)  and  modified  by  Blair  to  prevent  overlapping  of 
the   edges  in  suture  of  the  mucous  membrane,  is,  on  the  whole,  the 

most  satisfactory  skin  suture  I  have  used 
in  plastic  work,  as  it  prevents  retraction 
and  unevenness  of  the  epithelial  edges  of 
the  wound  (Fig.  49) .  A  continuous  su- 
ture of  a  similar  type  described  by  C.  S. 
White  is  also  useful  (Fig.  50). 

These  special  methods  of  suturing  in 
addition  to  the  proper  use  of  the  ordi- 
nary interrupted  suture,  the  continuous 
and  the  mattress  suture  (plain  or  modi- 
fied), are  sufficient  for  all  plastic  work. 
It  is  imperative  that  no  suture  of  any  kind 
should  be  tied  too  tightly. 

All  tension  should  be  relieved  by 
tension  sutures,  either  buried  or  remov- 
able, and  to  prevent  spreading  of  the 
scar,  the  fascia  under  the  skin  should  be 
carefully  sutured. 

An  excellent  removable  tension  su- 
ture which  leaves  no  scar  is  described 
by  R.  L.  Dickerson.     The  double  test- 
tube  or  roll  of  gauze  in  this  method  can 
be  used  with  either  metal  skin  clips,  or  with  the  single  on  end  mattress 


Pig.    50. — Continuous   on-end   mat- 
tress suture.      (C  5.  White.) 
This  is  an  excellent  suture  and  can 
be  inserted  very  rapidly. 


SILKWORM 
5TAY  STITCH 


CATGUT 
CONTINUOUS 


CATSUT 
CONTINUOUS 


STAY  STITCH    SWEEPS 
DIA60NAUY  THROUGH  SKIN 
EMER6IN6  AT  MARGIN 


t^L'PS^ 


SI  LKWO  RM^STITCH 
PERITONEUM 


Pig.   si. — A  removable  scarless  tension  suture.     (Dickinson.) 
The  diagram  shows  only  the  skin  and  subcutaneous  fat  included  in  the  suture.      This 
may  be  made  more  effective  by  passing  the  silkworm  gut  further  away  from  the  incision, 
and  as  deep  as  desired. 

suture,   without    causing    depression  of  the  everted  epithelial  edges 

(Fig.  5i)- 


GENERAL    CONSIDERATIONS 


29 


The  sutures  approximating  the  skin  edges  should  be  removed  in 
from  three  to  five  days,  and  leave  little  scarring. 

Needles  and  Suture  Materials.— In  plastic  work,  I  prefer  to  use  small 
cervical  needles  for  the  buried  sutures  when  they  are  necessary,  and 


mz^^^/k^^    -^:yy^::L^^^^^j^    "Z^^ZZ^/^s^     ^//'{//^jm^ 


Fig.   52. — Method  of  inserting  interrupted  sutures. 
A  and  B.  Wrong  method.     The  tissues  below  the  skin  are  not  approximated.     C  and 
D.  Proper  method.      All  the  tissues  are  approximated  and  no  dead  space  is  left. 

catgut  for  the  suture  material  if  there  is  any  possibility  of  infection, 
otherwise,  fine  silk  is  preferable.     For  the  skin,  I  find  half  curved  cor- 


FiG.  SZ-  Fig.   54. 

Pig.   53.— Method  of  removing  an  interrupted  suture. 

One  side  of  the  suture  is  raised  out  of  the  tissues  and  the  portion  which  has  been  buried 
is  cut  close  to  the  skin,  and  the  suture  drawn  through. 

Fig.   54. — Types  of  needles  useful  in  plastic  surgery. 

I  and  2.  Small  cutting  needles  designed  by  Lane  for  cleft  palate  work.  They  are 
very  useful  for  this  purpose,  and  also  in  positions  where  a  very  short  needle  is  necessary. 

3.  A  cutting  needle  about  the  size  of  the  small  round  French  needle,  but  easier  to  force 
through  resistant  tissues. 

4  and  5.  The  small  and  large  corneal  needles.  There  is  a  size  between  these.  I  prefer 
this  type  of  needle  for  closing  the  skin,  as  it  causes  the  minimum  amount  of  damage. 

6.  The  small  cervical  needle  which  is  useful  for  passing  buried  sutures. 

7.  The  straight  intestinal  needle  which  can  be  used  for  many  purposes.  If  a  very  short 
straight  needle  is  required,  this  thin  needle  can  be  broken  anywhere  in  its  length,  and  will 
pass  through  the  tissues  without  difficulty.  The  centimeter  scale  above  will  give  the  actual 
size  of  the  needles. 

neal  needles  satisfactory,  and  use  horsehair  preferably,  then  very  fine 
silk,  silkworm  gut,  or  silver  wire,  depending  on  the  indications  (Fig. 
54).      Special    small  curved  needles  (Lane)  are  used  for  cleft  palate 


30  PLASTIC    SURGERY 

work.  In  the  mouth  I  find  that  silkworm  gut  and  horsehair  are  best 
for  the  hard  and  soft  palates,  and  fine  silk  for  the  uvula.  For  the 
mucous  membrane  of  lips,  cheeks  and  tongue,  silk  or  catgut  is  used, 
as  indicated.  For  ligatures  fine  silk  or  catgut  should  be  used.  For 
tension  sutures  I  use  silkworm  gut  or  silver  wire,  tied  over  metal  plates, 
vulcanite  buttons  or  rubber  tubing. 

Methods  of  Closing  Wounds  Without  Sutures 

It  is  inadvisable  at  times  to  insert  stitches,  although  it  is  necessary 
that  the  edges  of  the  wound  should  be  approximated.  Sterile  strips 
of  adhesive  plaster  may  be  used  to  hold  the  margins  of  a  wound  in  appo- 
sition. Strips  of  adhesive  plaster  applied  close  to,  and  parallel  with, 
the  edges  of  a  wound  may  be  sutured  to  each  other,  and  accomplish 
the  same  purpose. 

Strips  of  muslin  to  which  tiooks  have  been  sewed  may  be  glued  to 
the  skin  with  one  of  the  adhesive  mixtures  mentioned  below,  and  the 
edges  of  the  wound  may  be  approximated  by  lacing.  ^  The  edges  may 
be  held  together  by  strips  of  sterile  crepe  lisse  which  are  fastened  to  the 
skin  with  flexible  collodion,  and  this  is  especially  valuable  for  closing 
wounds  of  the  face.  Small  metal  clips  of  various  kinds  may  also  be 
used  to  approximate  the  skin  edges  and  cause  little  pain  or  scarring. 
Broad  bands  of  adhesive  plaster,  or  muslin,  to  which  hooks  have  been 
sewed  may  be  placed  outside  the  margin  of  granulating  wounds,  and 
the  size  of  these  wounds  be  gradually  diminished  by  continuous  elastic 
traction  exerted  by  rubber  bands  placed  on  these  hooks,  and  crossing 

1  Adhesive  mixtures  for  gluing  muslin  bands  or  dressings  to  the  skin. 

Heussner's  Glue. — Rosin  25.  gm.;  alcohol  90  per  cent,  25.  c.c;  Venetian  turpentine 
0.5  c.c;  benzine  5.0  c.c. 

Glue  used  by  Polonowski  &  Durand. — Rosin  20.  gm.;  ligroin  2.5  c.c;  spirits  of  turpen- 
tine I.  c.c;  alcohol  10.  c.c 

Dieterich's  Varnish. — Rosin  15.  gm.;  Venetian  turpentine  i.  c.c;  castor  oil  0.5  c.c; 
benzol  35.  c.c;  soda  bicarb.  3.  gm.;  amyl  acetate  0.3  c.c 

Sinclair-Smith's  Glue. — Common  glue  25.  gm.;  water  25.  c.c;  glycerin  i.  c.c; 
thymol  0.5  gm.;  calcium  chloride  0.5  gm.  This  mixture  should  be  applied  hot,  and  can  be 
used  without  shaving  the  part  if  it  is  painted  on  the  skin  in  a  direction  opposite  to  that  in 
which  traction  is  to  be  made. 

I  have  used  the  mastic  dressing  of  Borchardt  fpure  gum  mastic  40.  gm.;  benzol  60.  c.c; 
castor  oil  20  drops)  for  gluing  dressings  to  the  skin,  but  it  is  difficult  to  handle  as  it  dries 
very  slowly,  and  remains  sticky  for  a  long  time. 

All  of  these  mixtures  are  satisfactory.  The  part  should  be  shaved  if  possible,  and 
washed  with  ether  or  benzine.  Then  the  mixture  should  be  painted  on,  and  the  band  or 
dressing  applied  over  the  painted  area.  After  the  mixture  has  dried  the  lacing  may  be  done, 
or  the  elastic  bands  be  put  in  position. 


GENERAL   CONSIDERATIONS  3 1 

the  wound  in  xarious  directions.  Muslin  applied  in  this  way  will  stay 
adherent  to  the  skin  from  ten  days  to  two  weeks,  and  is  much  more 
stable  than  adhesive  plaster.  There  is  sometimes  slight  irritation  of 
the  skin,  but  no  more  than  is  caused  by  adhesive  plaster. 

HEMORRHAGE 

Primary  Hemorrhage. — All  bleeding  vessels  of  any  size  should 
be  clamped  and  tied  with  catgut  or  tine  silk.  Smaller  vessels  may  be 
controlled  by  pressure  or  by  pinching  or  twisting  with  forceps.  An 
oozing  point  that  persists  can  often  be  checked  by  touching  it  with  a  fine- 
pointed  cautery.  The  application  of  i— looo  adrenalin  is  sometimes 
advisable.  Gauze  saturated  with  hot  salt  solution  is  also  efficacious 
in  stopping  a  general  oozing,  as  is  also  a  3  per  cent  peroxide  of  hydro- 
gen solution.  Horseley's  bone  wax  (carbolic  acid  i  part,  olive  oil  2 
parts,  w'hite  wax  7  parts)  may  be  used  to  plug  a  bleeding  point  in 
bone  by  forcing  it  into  the  defect.  Bits  of  muscle,  fat  or  fascia,  may 
be  used  to  check  hemorrhage. 

On  the  scalp,  or  in  angiomatous  tissue  an  over  and  over  continuous 
whipstitch  is  of  great  use. 

Temporary  packing  with  gauze  may  be  necessary,  and  this  is  often 
a  very  efiticient  method  of  checking  hemorrhage.  The  gauze  is  removed 
in  from  three  to  four  days,  and  if  the  w'ound  is  aseptic,  secondary  suture- 
ing  may  then  be  carried  out. 

Post-operative  Hemorrhage. — This  is  usually  due  to  the  slipping 
of  a  ligature,  or  the  expulsion  of  a  clot.  The  best  treatment  is  to  catch 
the  vessel  and  tie  it,  or  to  leave  the  clamp  in  place  for  a  day  or  two, 
if  it  is  impossible  to  tie.  Occasionally  it  is  necessary  to  tie  the  vessel 
proximal  to  the  bleeding  point.  Packing  is  often  sufficient  after  the 
removal  of  clots  and  cleansing  of  the  wound. 

Secondary  Hemorrhage. — This  as  a  rule  occurs  several  days 
after  operation  or  injurv,  and  is  usually  due  to  sepsis  wath  erosion  of 
a  vessel.  This  has  been  a  complication  in  war  wounds  of  the  jaws, 
which  has  caused  considerable  trouble.  The  treatment  is  the  same  as 
that  for  post-operative  hemorrhage. 

DRAINAGE 

Whenever  there  is  possibility  of  serum  or  blood  collecting  beneath 
a  flap  or  where  infection  is  feared  it  is  advisable  that  provision  be  made 


32  PLASTIC    SURGERY 

for  drainage.  This  is  especially  important  after  shifting  double-pedicled 
flaps  on  the  neck,  or  from  the  neck,  to  the  chin,  or  the  lip.  The  drains 
should  be  small,  and  should  be  placed  in  the  angles  at  the  most  depend- 
ent portion  of  the  wound.  Among  the  best  materials  for  this  purpose 
are  folded  strips  of  rubber  protective,  ordinary  rubber  bands,  very 
small  flat  cigarette  drains  of  iodoform  gauze  and  rubber  protective. 
Several  strands  of  twisted  catgut;  silkworm  gut,  or  horsehair,  may  be 
used.  Silver  wire  bent  in  the  shape  of  a  narrow  hairpin  is  useful  in 
selected  positions.  Narrow  strips  of  thin  celluloid  folded  lengthwise 
are  sometimes  satisfactory,  when  long  continued  drainage  is  necessary. 
Ordinarily  in  uncomplicated  cases  drains  should  be  partially  removed 
within  twenty-four  hours,  and  completely  removed  after  three  days. 
This  applies  to  the  non-absorbable  drains.  The  catgut  drains  are 
usually  absorbed  promptly  and  removal  is  unnecessary. 

DRESSINGS 

The  part  should  be  immobilized  as  effectively  as  possible  by  means 
of  plaster  of  Paris,  crinolin,  splints,  or  in  any  other  suitable  manner, 
since  physiologic  rest  is  important.  Soft,  carefully  applied  non-irritat- 
ing dressings  should  be  used,  and  secured  with  even  pressure.  Dress- 
ings which  are  too  tight,  or  in  which  the  pressure  is  uneven,  may  cause 
sloughing  of  a  flap  or  graft  which  would  otherwise  be  successful.  All 
dressings  around  the  mouth,  nose,  eyes  or  other  orifices,  should  be 
changed  frequently,  as  they  are  often  soiled  and  infection  may  follow. 

It  is  advantageous  to  inspect  the  flap  frequently,  because  by  loosen- 
ing stitches  where  strangulation  has  developed,  or  by  combating  a 
small  infection  promptly,  or  evacuating  fluid  which  has  collected  under 
the  flap,  it  may  be  possible  to  turn  what  would  otherwise  be  a  failure 
into  a  success. 

It  is  not  advisable  at  this  time  to  attempt  even  a  brief  outline  of  the 
dressings  used  by  different  surgeons,  as  their  name  is  legion.  The 
subject. will  be  considered  more  fully  under  the  section  on  the  treat- 
ment of  wounds. 

INFECTIONS 

Frequently  in  plastic  surgery  infections  have  to  be  dealt  with.  The 
wound  may  be  infected  when  the  case  appears  for  treatment,  or  infec- 
tion may  develop  during  treatment,  or  after  operation.  The  most 
dreaded  of  the  ordinary  infections  is  erysipelas.     It  is  not  uncommon 


GENERAL    CONSIDERATIONS  ^^ 

for  erysipelas  to  develop  after  operations  about  the  face,  or  it  may 
occur  at  any  time  in  unstable  scars,  or  around  chronic  ulcers.  The 
treatments  suggested  for  erysipelas  are  very  numerous.  I  will  mention 
the  only  one  which  I  have  found  to  be  uniformly  successful.  This 
method  of  treating  erysipelas  was  first  reported  by  Winckler.  My 
attention  was  called  to  it  by  Col.  W.  B.  Davis,  M.  C,  U.  S.  Army,  who 
has  used  it  in  his  army  work  since  1893,  i^  preference  to  any  other 
treatment.  The  following  mixture:  tannic  acid  dram  i;  camphor  drams 
iii;  ether  ounce  i,  is  thoroughly  shaken  and  filtered.  This  is  painted 
over  the  affected  parts  with  a  camel's-hair  brush  every  three  hours, 
a  whitish  coating  resulting.  Tt  is  essential  to  paint  at  least  one  inch 
beyond  the  visible  margin  of  the  infection.  The  coating  may  be  re- 
moved when  necessary  with  soap  and  water  for  the  purpose  of 
observation  after  which  the  mixture  may  be  reapplied  as  often  as 
necessary.  The  fever  will  usually  fall  within  24  hours,  and  the 
disease  be  controlled  within  a  few  days. 

Staphylococcus  infections  are  quite  common,  especially  about  the 
mouth  and  chin,  and  may  be  combated  with  the  mixture  mentioned 
above,  or  by  dressings  wet  with  hot  normal  salt  solution,  or  any  other 
solution  which  does  not  damage  the  tissues. 

When  abscess  forms  following  any  sort  of  infection,  the  pus  must  be 
evacuated,  and  the  cavity  treated  as  in  any  ordinary  case. 

Infection  with  the  Bacillus  Pyocyaneus  often  occurs,  and  is  espe- 
cially noticeable  in  cases  in  which  skin  grafting  has  been  done.  Ordi- 
narily it  is  of  little  consequence,  and  may  be  controlled  with  compresses 
saturated  with  1-50  permanganate  of  potash,  or,  better  still,  with  i  per 
cent  acetic  acid  solution. 

MASSAGE  AND  PASSIVE  MOTION 

The  intelligent  use  of  massage  is  very  important  in  plastic  surgery. 
Before  operation,  scars  may  be  made  movable  and  the  circulation  of 
adjacent  tissues  improved.  After  operation,  restoration  of  function 
is  hastened  by  massage  and  passive  motion,  and  areas  that  have  been 
grafted  may  be  loosened  and  the  color  and  circulation  of  the  flaps 
improved. 

Massage  of  the  operated  area  should  be  commenced  about  three 

weeks  after  operation,  and  if  the  healing  is  not  quite  complete,  the 

surrounding  skin  should  be  kept  in  good  condition  by  this  means.     The 

beneficial  effect  of  massage  in  plastic  and  reconstructive  surgery,  both 

3 


34  PLASTIC    SURGERY 

before  and  after  operation,  seems  to  have  been  lost  sight  of  to  a  large 
extent,  and  I  wish  to  emphasize  the  importance  of  its  systematic  use. 

ADVANTAGE  OF  KEEPING  GRAPHIC  RECORDS 

It  is  impossible  for  either  the  surgeon  or  the  patient  to  keep  in  mind 
the  changes  which  take  place  during  the  progress  of  a  case  requiring  a 
series  of  plastic  and  reconstructive  operations,  and  for  this  reason  it  is 
of  great  importance  that  accurate  graphic  records  be  kept  of  the  steps 
in  the  process. 

The  ideal  graphic  record  is  the  life-size  wax  model  painted  in  natural 
colors.  The  construction  of  these  models  requires  an  artist  especially 
trained  for  the  work,  but  up  to  this  time  the  method  has  been  unavail- 
able for  every  day  use. 

For  many  years  I  have  made  it  a  rule  to  take  series  of  photographs 
of  these  cases  showing  the  condition  before  operation,  and  also  the 
various  stages  of  the  reconstruction,  and  have  found  that  a  study  of  these 
unretouched  photographic  records  is  of  great  use  in  planning  further 
steps,  in  the  operative  work,  and  in  keeping  permanent  records. 

Plaster  casts  are  also  most  satisfactory,  and  should  be  utilized  when- 
ever possible;  especially  to  show  the  original  condition  and  progress 
made  in  the  treatment  of  defects  of  the  jaw,  palate,  and  nose. 

BIBLIOGRAPHY 

Aym.^ed,  G.  L.     "Lancet."     London,  May  12,  1906,  1314. 
"Lancet."     London,   Sept.    i,   1917,   347. 

Bartlett,  W.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  1912,  205. 
Bloodgood,  J.  C.     "Johns  Hopkins  Hospital  Reports,"  \di,  No.  5. 
B0KCH.A.RDT,  M.     "Beitr.  z.  klin.  Chir.,"  Oct.,  1913,  453. 

BuROW,  C.  A.     "Zum  Wiederersatz  Verloren-gegangener  Theile  des  Gesichts."     Berlin, 
1855- 

D.AVis,  J.  S.     "J.  A.  M.  A.,"  July  29,  1916,  338. 

"Anns.  Surg.,"  Feb.,  1917,  170. 
FJiCKERSOX,  R.  L.     "Long  Island  Med.  Jour.,"  Jan.,  1915,  66. 
DizTRiCK,  K.     "Munchen  med.  Wchnschr.,"  Nov.  10,  1914,  No.  45. 

V.  EsMARCH,  F.     "Handbuch  der  Kriegschirurgischen  Technik,"  1894,  135. 

GoYANES.     "Siglo  Medico,  Madrid,"  April  21,  1917,  226. 

H.ALSTED,  W.  S.     "Johns  Hopkins  Hosp.  Bull.,"  Dec,  1889,  13. 

"Johns  Hopkins  Hosp.  Bull.,"  March,  1893,  21. 

"j.  A.  M.  A.,"  April  12,  1913,  11 19. 
Hedges,  E.  W.     "J.  Med.  Science,  X.  J."     Orange,  1912-13,  .^x,  279. 
Heussxer.     Quoted  by  Blake  &  Bulkley:  "Surg.,  Gyne.  &  Obst.,"  March,  1918,  247. 


GENERAL    CONSIDERATIONS  35 

Kapp,  J.  F.     "Med.  Klin.,"  March  30,  1913,  ixj  Xo.  13. 
Keetley,  C.  B.     "Anns.  Surg.,"  vol.  vi,  1887,  97. 

M.\cCoR.vi.\c.  Sir  W.     "Treatment."     London,  iSSq-iqoo,  iii,  pp.  37,  169,  301,  433,  561. 
M.\CHEK,  E.     "Archives  of  Ophthalmology."     New  Rochelle,  X.  V.,  Sept.,  1915,  X'o.  5, 

539- 
Macht,  D.  I.     "Jour.  Pharmy.  &  E.\p.  Therap.,"  xi,  .\pril,  1918,  263. 

"Trans.  Assn.  Anier.  Physicians,"  J.  .\.  M.  A.,  June  8,  1918,  1790. 
Marcy,  H.  O.     "Lancet-Clinic,"  X'^ov.  16-23,  191 2. 
McMiLLEX,  P.  M.     "West  Va.  Med.  Jour.,"  Sept.,  1909,  90. 
MoRESTix,  H.     "Jour,  de  Chir."     Paris,  Xov.,  1911. 
MiHLiiAUS,  R.     "Munchen  med.  Wchnschr.,"  May  11,  1915,  668. 
V.  MLTSCHENB.4CHER,  T.     "  Beitrag.  z.  klin.  Chir.,"  April,  1913,  Ixxxiv,  208. 

Perry,  R.  ST.  J.     "Amer.  Jour.  Clin.  Med.,"    Jan.,  1915. 

Raxsohoff,  J.     "Ref.  Handb.  Med.  Sc,  X.  Y.,"  1917,  vii,  240. 
Reder,  F.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  1913,  218. 
RocKEV,  A.  E.     J.  A.  M.  A.,  July  20,  1918,  183. 

SiiUFELDT,  R.  \V.     "Med.  Rec."     X.  Y.,  1918,  xciv,  663. 

Sixcl.air-Smith.     Quoted  by  Blake  &  Bulkley.     "Surg.,  Gyne.  &  Obst.,"  March,  1918,  247. 

Sterxberg,  J.     "Oregon  State  Med.  Assn.,"  1908,  98. 

"Wiener  klin.  Wchnschr.,"  July  15,  1915. 
Stieglitz,  G.     "Surg.,  Gyne.  &  Obst.,"  August,  1918,  231. 

White,  C.  S.     "Surg.,  Gyne.  &  Obst.,"  ]\Lirch,  191 7,  373. 
WixcKLER.     "Univ.  ;Med.  Mag.,"  March,  1893,  477. 

Transplantation    u.    Plastik   and   Plastik   u.   Transplantation.      Verhandl.   d.    Deutsch, 
Gesellsch.  f.  Chir.,  1910  and  1911. 


CHAPTER  III 
PROSTHESIS 

Ambroise  Pare  defined  prosthesis  as  comprising  all  "methods  and 
devices  for  supplying  that  which,  from  natural  or  accidental  causes  is 
lacking." 

In  plastic  surgery  prosthetic  methods  may  be  dividedviito  two  groups. 

I.  External. — Applied  to  those  cases  in  which  the  prosthesis  remains 
in  communication  with  the  outside  air.  2.  Internal. — Applied  to  those 
cases  in  which  the  prosthesis  is  buried,  and  has  no  communication  with 
the  outside  air. 

The  success  of  internal  prosthesis  depends  on  absolute  asepsis,  and 
on  the  tolerance  of  the  tissues  for  certain  inorganic  substances.  Among 
the  inorganic  materials  used  for  prosthetic  apparatus,  both  external  and 
internal,  are  the  following:  rubber  (soft  and  vulcanized),  gutta  percha, 
gold,  silver,  platinum,  tin,  German  silver,  aluminum,  copper  and  steel, 
glass,  porcelain,  ivory,  celluloid,  and  paraffin. 

External  Prosthesis. — Those  who  have  not  learned  by  experi- 
ence to  appreciate  the  possibilities  of  plastic  and  reparative  surgery 
are  inclined  to  the  opinion  that  all  large  facial  defects  should  be 
treated  with  prosthetic  apparatus.  In  some  cases,  especially  those 
following  the  ravages  of  disease,  a  full  or  partial  mask  may  be  necessary, 
but  in  the  great  majority  of  traumatic  cases  it  is  better  to  reconstruct 
the  destroyed  parts  of  the  face  from  the  patient's  own  tissues. 

Temporary  prosthesis  to  prevent  contracture  is  absolutely  essential 
in  many  wounds  of  the  face  involving  the  bony  framework. 

Unquestionably  an  artist  can  construct  an  artificial  nose  or  chin, 
which  will  be  cosmetically  more  perfect  than  anything  the  surgeon  may 
be  able  to  build.  At  the  present  time,  indeed,  a  number  of  sculptors 
and  other  artists  are  doing  this  work  in  England  and  France,  and  several 
are  already  working  in  this  country  (Figs.  55,  56  and  57).  Their 
results  are  splendid  as  far  as  they  go.  I  believe,  however,  that  in 
the  majority  of  cases  this  work  should  be  only  a  temporary  measure, 
used  to  cover  the  defect  during  the  intervals  in  the  process  of  con- 
struction, or  to  conceal  the  deformity  until  the  patient  can  be  placed 

36 


PROSTHESIS 


37 


under  the  care  of  a  skilled  plastic  surgeon.  It  is  needless  to  say  that 
the  operative  work  on  such  extensive  cases  should  be  done  only  by  the 
most  experienced  plastic  surgeons,  and  it  is  far  better  for  the  patient 
to  continue  to  wear  his  prosthetic  apparatus  than  to  be  operated  on 
by  the  first  comer. 


A  B 

Fig.   55. — Mask  for  both  eyes. 

A.  Patient  without  the  mask. 

B.  The  mask  held  in  place  by  means  of  a  spectacle  frame. 

This  splendid  mask  and  those  following,  were  made  by  Mrs.  Maynard  Ladd,  the  Boston 
sculptor,  while  on  duty  in  Paris  (after  the  entrance  of  the  United  States  into  the  war) 
under  the  auspices  of  the  American  Red  Cross.  Seventy  masks  were  made  in  her  studio. 
They  are  accurate  reproductions  of  the  missing  parts  modeled  from  photographs  and 
measurements,  and  these  masks  are  painted  to  match  the  surrounding  skin.  Masks  of  this 
type  are  of  great  value  to  patients  beyond  the  aid  of  the  plastic  surgeon,  and  are  most 
useful  to  patients  in  the  intervals  between  reconstructive  operations, 

Capt,  Whale,  writing  in  September,  191 7,  says  that  in  General 
Hospital  83,  B.E.F.  in  France  (which  was  established  especially  for 
plastic  work)  that  only  one  man  among  all  those  treated  has  elected  to 
go  to  England  for  a  permanent  mask  prosthesis,  rather  than  undergo 
a  series  of  operations  for  the  plastic  repair  of  his  defect. 

Artificial  noses  are  usually  held  on  with  spectacles,  with  springs 


38 


PLASTIC    SURGERY 


or  plugs  placed  in  the  nasal  defect,  or  by  a  support  attached  to  a  dental 
plate,  or  to  a  tooth.  Entire  facial  masks  may  be  held  in  place  with 
spectacles.  In  other  instances  with  skin-lined  loops  or  pockets,  made 
by  the  surgeon  to  hold  pegs  attached  to  the  mask.  Combinations  of 
these  methods  of  securing  masks,  in  addition  to  a  strongly  adhesive 
glue,  are  often  used. 

The  nose  alone  may  be  made,  or  the  nose  and  upper  lip  with  mus- 
tache, or  the  chin,  etc. 


A  B 

Fig.   56. — Mask  for  the  chin.      (Mrs.  Maynard  Ladd.) 

A.  Patient  without  the  mask. 

B.  The  mask  in  place.      The  necessary  dressings  may  be  placed  in  the  mask  to  absorb 
the  saliva  which  is  constantly  dripping  in  some  of  these  cases. 


These  prostheses  must  be  carefully  molded.  Some  are  made  of 
thin  metal,  others  are  of  soft  or  hard  rubber;  papier  mache,  or  porce- 
lain; others  again  of  plastic  paste  or  wax,  all  being  colored  to  match 
the  surrounding  skin. 

The  technic  of  making  a  facial  mask  is  rather  complicated,  the 
following  being  the  process  used  by  R.  Tait  McKenzie: 


PROSTHESIS 


39 


"i.  The  deformed  part  of  the  face,  and  the  surrounding  regions  are  lubricated 
with  white  vaseline,  care  being  taken  to  fill  the  hair  spaces  in  the  eyelids,  and  the 
eyelashes.  A  quick-setting  plaster  of  Paris  is  mixed  and  when  it  is  of  the  consist- 
ency of  thick  cream,  it  is  gently  painted  over  the  sound  tissue  with  a  soft  brush, 


3  *^ 


rt  M 


^1 

o  c 


?«  ^    C 


6  = 

<u   u 


a  a  ^ 


^cq 


until  the  surface  is  covered.  Care  must  be  taken  to  leave  a  breathing  space  at  the 
nose  and  mouth,  and  to  see  that  the  face  is  not  unnaturally  drawn  or  wrinkled  from 
nervousness.  The  plaster  is  strengthened  and  thickened,  until  it  forms  a  sheet 
about  one  inch  in  thickness.  When  this  has  become  set,  as  shown  by  the  heat,  it 
is  carefully  drawn  oflf. 

"  2.  This  mold — the  negative — is  well  soaped  with  green  soap,  oiled,  and  a  cast — 


40  PLASTIC    SURGERY 

the  positive — is  made  and  trimmed  to  the  required  shape  and  thickness.     This 
serves  as  a  record  or  original  of  the  deformed  face. 

"3.  From  this  model,  a  glue  mold,  or  negative,  is  made. 

"4.  Several  casts  may  now  be  made  from  this  mold,  and  colored  by  water  color, 
to  match  the  plasteHne,  which  is  used  in  the  next  process. 

"5.  With  the  patient  present,  and  by  reference  to  photographs,  the  missing 
nose  is  modeled  on  one  of  these  casts,  great  care  being  taken  to  imitate  the  surround- 
ing surface  textiire  and  match  it,  especially  at  the  edges.  It  is  safer  to  model  this 
in  plasteUne,  over  the  plaster,  rather  than  on  a  plasteline  squeeze,  as  described  later, 
if  at  all  possible,  because  the  hard  plaster  prevents  one  making  the  possible  error  of 
going  too  deep  in  modeling  a  hollow.  Where  a  missing  eye  has  to  be  reproduced, 
another  process  is  necessary  at  this  stage. 

"6.  A  piece  mold  must  be  made  from  the  cast  (4).  It  is  prepared  with  French 
chalk,  and  (6  A)  a  plasteline  squeeze  made.  The  sculptor  then  opens  the  eye  by 
modeling  it  from  life  (6  B),  because  the  eye  was  closed  during  the  taking  of  the 
original  mold  over  the  face. 

"7.  A  glue  mold  must  then  be  made,  from  this  plasteline  cast  of  the  remodeled 
eye,  the  sound  one,  and 

"8.  A  cast  is  made  from  this,  as  in  4,  the  process  going  on  as  in  5. 
"g.  When  the  missing  features  have  been  modeled  to  the  satisfaction  of  the 
sculptor  and  the  patient,  a  glue  mold  is  made  of  the  restored  face,  from  which 
"  10.  A  cast  in  wax  is  made  and  worked  on  or  retouched,  if  necessary. 
"11.  The  wax  is  now  carefully  coated  with  bronze  powder,^  or  plumbago,  con- 
nected by  copper  wire  with  the  cathode  of  a  dry  ceU  battery,  and  placed  in  a  galvano 
deposit  bath  of  sulphuric  acid  and  sulphate  of  copper,  between  two  copper  plates 
connected  with  the  anode.     It  is  left  there  until  a  film  of  copper  one  thirty-second 
of  an  inch  in  thickness  is  deposited,  a  process  lasting  four  or  five  hours.     This  is  a 
process  in  which  many  failures  are  hkely  to  occur,  until  a  good  deal  of  experience 
is  gained. 

"12.  The  wax  is  now  melted  out,  and  the  metal  mask  trimmed  and  tried  on. 
Every  advantage  must  be  taken  of  natural  lines  and  wrinkles  of  the  face,  to  hide 
the  borders.  The  nostril  holes  are  opened,  as  well  as  the  eye  sHt,  which  masks  the 
missing  eye. 

"13.  The  mask  is  then  electroplated  with  silver  by  dipping  in  a  solution  of 
nitrate  of  silver,  and 

"  14.  When  the  eye  has  to  be  replaced,  the  artificial  glass  eye  is  matched  with 
the  good  eye,  or,  better  stiU,  a  blank  one  is  painted  to  match,  and  then  placed  and 
held  in  place  behind  the  open  lids  by  wire  cUps,  hke  the  setting  of  a  jewel  in  a  ring. 
This  fitting  requires  great  care  and  patience. 

"15.  The  mask  is  now  given  a  coat  of  color,  and  the  complexion  is  matched  with 
great  care,  using  oil  colors  with  a  wax  medium.  The  success  of  this  will  depend 
entirely  upon  the  artistic  skill  of  the  painter. 

"16.  When  this  is  completed,  a  pair  of  spectacle  frahies,  with  heavy  rims,  are 
fitted  on  over  the  mask,  and  the  nose  piece  is  riveted  through  the  copper,  or  soldered 
to  hold  them  in  place.  When  a  cheek  is  replaced,  it  may  be  necessary  to  have  a  pin 
from  the  spectacle  frame  to  the  mask,  to  give  the  gentle  pressure  necessary  to  keep 
it  in  place. 


PROSTHESIS 


41 


"17.  Eyebrows  can  be  made  with  real  hair,  or  by  painting  them,  and  eyelashes 
are  best  made,  in  the  experience  of  Dervvent  Wood,  of  tin  foil,  cut  in  thin  strips, 
colored  and  soldered  to  the  edge  of  the  eyelid.  They  can  also  be  set  with  real  hair 
in  a  groove  of  the  lid,  and  held  by  wax." 

As  can  be  seen  this  process  is  quite  complicated  and  should  only 
be  undertaken  by  one  experienced  in  this  sort  of  work  (Figs.  58,  59 
and  60). 

A  simpler  method  is  that  used  by  Pont.  In  cases  which  cannot  be 
benefited  by  surgical  procedures,  he  gives  the  patient  a  mold  and 
plastic  paste,    so   that   he  can  make  a  new  artificial  nose  whenever 


Fig.  58. — Masking  a  facial  deformity. 
Destruction  of  the  face  from  the  bridge  of 
the  nose  to  the  lower  jaw.     {Tail  McKenzie.) 


Fig.  59. — The  mask  in  place  on  the  pa- 
tient. This  mask  was  constructed  accord- 
ing to  the  directions  found  in  the  text. 
{Tait  McKenzie.) 


necessary.  Of  late  he  has  furnished  an  apparatus  for  making  wax 
models,  and,  if  necessary,  a  new  nose  can  be  made  each  day  and  easily 
appHed. 

The  artificial  eye  is  of  interest  to  the  plastic  surgeon,  inasmuch 
as  he  is  called  upon  at  times  (when  the  orbit  is  obliterated  by  scar 
tissue),  to  construct  a  cavity  to  contain  the  eye.  On  one  or  two  occa- 
sions I  have  found  it  very  difficult  to  make  this  cavity  permanent. 

Artificial  ears  are  best  made  of  a  soft  rubber  composition  which 
is  flexible.  The  ear  can  be  molded  and  colored  to  match  exactly  the 
intact  organ.  It  is  held  in  place  with  an  adhesive  paste,  or  with  a  skin 
loop,  or  with  springs  or  wires. 


42 


PLASTIC    SURGERY 


As  the  reconstruction  of  a  completely  destroyed  ear  is  extremely 
difficult  from  the  standpoint  of  appearance,  the  permanent  use  of  such 
a  prosthesis  is  advisable.  Pont  also  furnishes  a  carefully  prepared 
mold  and  plastic  paste  to  patients  requiring  artificial  ears,  so  that  they 
can  change  the  prosthesis  whenever  necessary. 


Fig.  6o. — The  mask  itself  has  been  colored  to  match  the  surrounding  tissues.  Mustache 
and  whiskers  are  in  place.  This  prosthesis  is  held  on  by  means  of  spectacles.  {Tail 
McKenzie.) 

In  those  cases  in  which  operative  procedures  are  inadvisable  for  the 
repair  of  defects  in  the  hard  palate,  obturators  have  been  made  to  fill 
the  defect.  To  these  in  some  instances  artificial  vela  have  been  at- 
tached, to  take  the  place  of  the  defective  soft  palate.     More  or  less 

success,  as  far  as  improvement  of  speech  is 
concerned,  has  been  reported  following  the 
use  of  these  obturators. 

Internal  Prosthesis.— In  plastic  surgery 
it  is  better  to  avoid  the  use  of  any  inorganic 
material  for  a  buried  supporting  framework. 
When  inorganic  material  is  used  for  internal 
prosthesis  immediately  under  the  skin,  any 
injury  may  cause  necrosis  of  the  skin,  and 
the  formation  of  a  sinus  which  will  persist 
until  the  prosthesis  is  removed.     When  in- 
serting   prosthetic    apparatus    the  incisions 
should  be  made  so  that  the  suture  line  is 
not  immediately  over  the  prosthesis.     It  is  advisable  to  cover  the  pros- 
thesis with  subcutaneous  tissue  before  suturing  the  skin,  or  when  it  is 
placed  in  a  tunnel  to  have  the  tunnel  beneath  the  subcutaneous  tissue. 
Of  the  materials  best  tolerated  by  the  tissues  those  most  often  used 


Fig.  6i. — Method  of  hold- 
ing an  artificial  nose  in  place 
by  means  of  springs.  {Port.) 
The  plugs  A  and  A'  are  on 
springs. 


PROSTHESIS 


43 


are   vulcanized   rubber,  or  one  of  the  metals,  silver  being  probably 
the  best  for  general  use. 

Celluloid  is  well  tolerated  by  the  tissues  and  causes  no  irritation.  In 
experimental  work  I  have  found  it  unchanged  after  having  been 
buried  in  muscle  tissue  for  months.  ]\Ionks  in  1898  used  it  for  building 
out  a  bridge  in  correcting  saddle  nose.  G.  S.  Thompson  writes  enthusi- 
astically on  the  surgical  uses  of  celluloid  buried  in  the  tissues.  He 
says  that  it  should  be  molded  to  fit  the  place  intended  for  it,  and 
advises  that  it  be  freely  perforated.  He  has  used  it  in  many  situations 
with  success  (Fig.  63). 


Fig.   62. — Method  of  holding  an  artificial  nose  in  place  by  means  of  a  dental  plate.      (Port.) 
At  .4    there  is  a  bayonet  lock. 

C.  Higgins  used  celluloid  plates  to  support  the  skin  and  prevent 
recurrence  of  retraction  in  scars.  Later  he  undermined  the  scars 
through  a  small  incision  and  injected  a  semisolid  mass  of  cellu- 
loid dissolved  in  acetone  into  the  undermined  tract.  This  was  soon 
solidified  and  accomplished  the  same  result.  I  have  not  tried  the 
methods  advocated  by  Higgins.  but  they  seem  unnecessary,  if  the 
surgical  treatment  of  depressed  scars  is  understood. 


SUBCUTANEOUS  HYDROCARBON  PROSTHESIS 

The  injection  of  paraffin  has  been  advocated  by  a  number  of  workers 
and  is  principally  used  for  the  correction  of  certain  deformities  about 
the  face,  shoulders  and  breast. 


44  PLASTIC    SURGERY 

Gersuny  in  Vienna,  in  1899.  injected  vaselin  subcutaneously  for 
the  correction  of  a  saddle  nose.  Delanger  about  the  same  time  injected 
spermaceti   for   the   same   purpose.       Vaselin   with   a    melting    point 


Fig.  63. — Celluloid,  molded  and  cut  in  various  shapes,  for  implantation  into  different 
regions.  (About  one-half  size. J  (Thompson.) 
I,  Filigrees  for  inguinal  hernia;  2,  filigrees  for  femoral  hernia;  3,  filigrees  for  umbilical 
hernia;  4,  filigrees  for  post-operative  hernia;  5,  nasal  bridge;  6,  bridge  for  spina  bifida. 
7,  celluloid  pegs  for  bone  fractures;  8,  celluloid  plate;  9,  joint  cap  for  covering  bone  in 
arthrodesis  (rough  representation);  10,  flanges  for  drainage  tubes;  11,  skull  plates  (inner 
without  perforation,  except  at  edges;  iia,  skull  plate  (outer);  12,  dust-proof  cover  for 
surgical  bottles;  13,  molded  cap  for  bone  end. 

of  .33°  to  39" C.  ^91.4°  to  io2.2°F.)  was  found  to  be  too  soft,  and  slow 
absorption,  or  diffusion  often  took  place.  Embolism  also  occasionally 
occurred. 


PROSTHESIS  45 

A  mixture  of  vaselin  and  paraffin  was  then  tried,  having  a  melting 
point  between  42°  and  46°C.  (107.6°  and  ii4.8°F.).  Eckstein  in  1901 
used  pure  paraffin  with  a  melting  point  of  6o°C.  (i40°F.),  instead  of  the 
vaselin-paraftin  mixture.  It  has  since  been  found  that  paraffin  with 
a  melting  point  of  about  52°C.  (125. 6°F.)  is  to  be  preferred. 

In  a  number  of  cases  in  which  paraffin  was  injected  into  the  tissue 
of  the  nose,  there  has  occurred  an  embolism  in  the  central  artery  of  the 
retina,  which  caused  immediate  and  permanent  blindness.  Pulmonary 
embolism  has  occurred,  and  thrombophlebitis  has  also  followed  these 
injections.  Connell  has  tabulated  a  number  of  untoward  results  following 
the  injection  of  paraffin,  and  Kolle  has  added  to  the  hst  which  follows: 

Untoward  Results 

1.  Toxic  absorption. 

2.  Marked  inflammatory  reaction. 

3.  Loss  of  tissue,  due  to  infection  and  abscess  formation. 

4.  Pressure  necrosis,  caused  by  hyperinjection. 

5.  Sloughing  of  tissue  as  a  result  of  the  heat  of  the  material  injected. 

6.  Sloughing  due  to  injection  into  very  dense  or  inelastic  structures, 
or  where  scar  tissue  is  firmly  attached  to  the  underlying  and  adjacent 
parts. 

7.  Subinjection  of  too  small  an  amount  of  paraffin  with  an  insufficient 
correction  of  the  deformity. 

S.  Hyperinjection  with  overcorrection  of  deformity. 
9.  Air  embolism. 

10.  Paraffin  embolism. 

1 1 .  Primary  diffusion  or  extension  of  paraffin  (when  first  introduced) 
into  adjacent  normal  structures. 

12.  Interference  with  muscular  action  of  the  nose. 

13.  Escape  of  paraffin  after  the  withdrawal  of  the  needle. 

14.  Sohdification  of  the  paraffin  in  the  needle,  which  renders  the 
injection  difficult  and  causes  injudicious  expedition  on  the  part  of  the 
operator. 

Absorption  or  disintegration  of  the  paraffin. 
The  difficulty  of  procuring  paraffin  at  the  proper  melting  point. 
Hypersensitiveness  of  the  skin  over  the  injected  area. 
Redness  of  the  skin  over  the  injected  area. 
Secondary  dift'usion  of  the  injected  mass. 

Hyperplasia  of  the  connective  tissue  following  the  organization 
of  the  injected  matter. 


16 

17 
18 

19 

20 


46 


PLASTIC    SURGERY 


21.  A  yellow  appearance  and  thickening  of  the  skin  after  organiza- 
tion of  the  injected  mass. 

22.  The  breaking  down  of  tissue  and  a  resulting  abscess  due  to  the 
pressure  of  the  injected  mass  upon  the  adjacent  tissue  after  the  injection 
has  become  organized. 

Some  authors  say  that  the  injected  paraffin  is  encapsulated 
like  any  other  foreign  body.  Others  claim  that  the  mass  is  first  sur- 
rounded by  a  connective  tissue  wall  and  that  fibrous  bands  are  then 
formed  which  penetrate  the  mass.  Eventually  the  paraffin  is  said  to 
be  absorbed  and  in  its  place  is  left  a  connective  tissue  mass  which  is 
hard  and  resistant  to  the  touch. 

In  my  operative  work  on  these  cases  I  have  found  that  both  condi- 
tions are  present  even  after  several  years  have  elapsed.     The  connective 


Fig.  64. — Paraffinoma. 
Note  the  thickening  of  the  tissues  of  the  nose,  cheeks  and  lips,  and  the  obUteration 
of  all  the  natural  lines.  The  mucous  membrane  was  also  involved  in  this  case,  and  the 
patient  was  unable  to  masticate  without  biting  the  projecting  folds.  Paraffin  had  been 
injected  two  years  previously,  several  times  for  the  purpose  of  eradicating  wrinkles.  The 
skin  was  purplish-red  and  very  dense  and  hard. 


tissue  mass  is  hard  enough  to  blunt  the  edge  of  a  scalpel,  and  in  cutting 
into  this  tissue  I  often  find  that  flakes  of  paraffin  are  floated  up  in  the 
blood.     These  tissues  are  difficult  to  handle  surgically. 

There  may  be  a  large  number  of  patients  who  have  been  perma- 
nently benefited  by  the  injection  of  paraffin,  but  a  glance  at  the  Hst 
of  untoward  results  is  enough  to  discourage  the  most  daring  surgeon 
who  has  any  regard  for  the  safety  of  his  patient.  The  terrible  uncor- 
rectable deformities  produced  by  the  development  of  paraffinoma 
months  after  apparently  successful  injection  of  paraffin,  have  only  to 
be  seen  once,  to  further  discourage  any  one  desiring  to  use  this  method 
(Fig.  64). 

Occasionally  the  tumor  masses  of  paraffinoma  show  themselves 
under  the  mucous  membrane  of  the  cheeks  and  lips  and  project  into 


PROSTHESIS  47 

the  mouth,  so  that  it  is  difficult  for  the  victim  to  chew  without  biting 
the  mucous  membrane. 

The  technic  for  the  injection  of  paraffin  is  simple  and  the  injections 
can  be  given,  after  a  little  practice,  by  anyone  who  is  able  to  purchase  the 
equipment.  The  immediate  results,  when  none  of  the  untoward  hap- 
penings occur,  are  at  first  very  gratifying  to  the  patient.  Never- 
theless, the  paraffin  frequently  shifts  its  position,  and  gradually 
trickles  down  the  tissue  planes,  or  the  infiltrated  tissues  may  thicken 
and  cause  deformities  which  are  infinitely  worse  than  the  original 
defect. 

The  injection  of  paraffin  is  the  sheet  anchor  of  the  "quack"  facial 
specialist. 

I  am  sure  that  all  those  who  have  seen  the  disastrous  efTects  following 
paraffin  injections  will  agree  with  me  that  this  method  of  internal 
prosthesis  is  a  poor  surgical  procedure. 

BIBLIOGRAPHY 

BiNNiE  &  Stark.     "Jour.  Missouri  Med.  .^ssn.,"  Oct.,  191 7,  .^iv,  415. 

Bkanchu.     "Lyon  Chir.,"  May-June,   1Q17,  608. 

Broeckaert,  J.     "Larynx  (etc.)  Marseille  &  Paris,"  1913,  vi,  161. 

Brown,  S.  H.     "Anns.  Otology.  Rhinol.  &  Laryngol."     St.  Louis,  March,  1915,  95. 

CoNNELL,  F.  G.     "J.  A.  M.  A.,"  1903,  xli,  697. 
CuxNiN'GHAM,  W.  F.     "Brit.  Med.  Jour.,"  1918,  ii,  376. 

Davis,  A.  E.     "J.  A.  M.  A.,"  July  20,  1917,  215. 

Delangre.     "Arch,  internal,  de  laryngol.  (etc.)."     Paris,  1903,  xvi,  366. 

Douglas,  S.  R.     "Lancet."     London,  1916,  ii,  558. 

Eckstein,  G.     "Prag.  med.  Wchnschr.,"  1901,  xxvi,  215. 

Fein,  J.     "Wien.  med.  Wchnschr.,"  1914,  l.xiv,  929. 

Gersuny,  R.     "Ueber  cine  subcutane  Prothese." 

"Ztschr.  f.  Heilk.  Wien  u.  Leipz.,"  1900,  n.  F.,  i,  199. 
Gillies,  H.  D.  &  King,  L.  A.  B.     "Lancet."     London,  1917,  i,  412. 

Hartung,  F.     "Deutsche  med.  Wchnschr.,"  Aug.  21,  1913,  Xr.  34. 
Heidingsfeld,  M.  L.     "J.  A.  M.  A.,"  Dec.  12,  1908,  2028. 
Heusner,  H.  L.     "Deutsche  med.  Wchnschr.,"  May  13,  1915,  Nr.  20. 
Higgins,  C.     "Lancet."     London,  Oct.  7,  1916,  643. 

KoLLE,  F.  S.     "Plastic  and  Cosmetic  Surgery,"  191 1. 

Ladd,    Mrs.  ^Lvynard.     "La  Presse  Med."     Paris,  No.  30,  ^lay  30,  1918,  345. 
Lagarde.     "J.  de  med.  de  Par.,"  1913,  2  s.,  xxv,  423. 

McKenzie,    R.  Tait.     "Reclaiming  the  Maimed,"  1918. 

M.ARTINIER,  p.  &LEMERLE,  G.     " Injuries  of  the  Face  and  Jaw,  and  Their  Repair,"  191 7. 

(Translated  by  G.  H.  Whale,  1918.) 
Monks,  G.  H.     "Boston  Med.  &  Surg.  Jour.,"  Sept.  15,  189S,  261. 


48  PLASTIC    SURGERY 

Pare,  Ambroise.     "Oeuvres  Complete,  Lyon,"  1646,  23,  livre,  572. 

Payne,  J.  L.     "Brit.  Jour.  Dent.  Sc."    London,  1917,  Ix,  425. 

Pont,  A.     "  Rhinoplastie  et  Prothese  Nasale."     "Lyon  Med.,"  1917,  cxxvi,  508. 

Ann.  di.  odont.  Roma,"  1916,  i,  614. 
Port,   G.     "Handbuch  d.   Speziellen  Ctiir."     Katz,  Preysing,  and  Blumenfeld.   Bd.   i. 

Heft.   2,   1912,   103. 
Port,  K.     "Zentralbl.  f.  Chir.  u.  mechan.  Orthopadie  Bd.,"  viii.  Heft,  i. 
PusEY,  W.  A.     "The  Principles  and  Practice  of  Dermatology,"  p.  865. 
PuTTi,  V.     "Chir.  d.  organ,  d  mov."     Bologna,  1917,  i,  419. 

Smith,  H.     "J.  A.  M.  A.,"  Sept.  26,  1903,  773. 

Speleers,  R.     "  Nederlandsch  Tijschrift  v.  Geneeskunde."     Amsterdam,  July  4,  1914, 

No.  I. 
Stein,  A.  E.     "Handbuch  d.  Speziellen  Chir."     Katz,  Preysing,  and  Blumenfeld.  Bd.  i, 

Heft.   2,   1912,   177. 
Stein,  Albert  S.     "Berl.  klin.  Wchnschr.,"  1901,  xxxviii,  840. 
Stein,  Albert  S.     "Berhner  klin.  Wchnschr.,"  Aug.  17,  1908,  xlv,  1523. 

Thompson,  G.  S.     "Brit.  Jour.  Surg.,"  1916,  iii,  696. 

Valadier  &  Whale.     "Brit.  Jour.  Surg.,"  July,  1917,  151. 

Valois,   G.      'Les  Borgnes  de  la  Guerre  Prothese  Chlrurgical  and  Plastique."       Paris, 

1918. 
Vansant,   E.     "Laryngoscope,".   Sept.,    1913,   908. 

Walsh,  D.     "Med.  Press  &  Circular."    London,  May  31,  1911. 

Wood,  F.  D.  &  Cruise  &  H.\stings.     "J.  Roy.  Army  Med.  Corps."    London,  1916, 

xxvi,  324. 
Wood,  F.  D.     'Lancet."    London,  June  23,  1917,  949. 


CHAPTER  IV 
THE  TRANSPLANTATION  OF  SKIN 

Skin  grafting  and  plastic  surgery  are  very  closely  linked  together. 
There  is  rarely  an  extensive  plastic  operation  done  in  which,  at  some 
stage,  it  is  not  necessary  to  graft  skin.  The  plastic  surgeon  should 
be  thoroughly  skilled  in  the  technic  and  be  able  to  utilize  any  type  of 
graft  which  may  be  necessary.  I  shall  consider  in  detail  only  the  tech- 
nic of  those  methods  which  have  proved  satisfactory  to  me. 

In  order  to  avoid  repetition  the  various  procedures  required  in  all 
the  methods  will  be  described  before  the  technic  of  the  methods  them- 
selves is  discussed. 

GENER.^  CONSIDERATIONS 

Source  of  Grafts. — Grafts  may  be  obtained  from  almost  any  portion 
of  the  skin.  The  region  from  which  it  is  taken  has  little  if  any  effect 
on  the  success  or  failure  of  the  graft. 

It  was  at  one  time  thought  that  skin  taken  from  a  part  corresponding 
exactly  with  the  defect  would  heal  better,  but  this  has  been  disproved. 
Von  Langenbeck  says:  "It  was  thought  in  former  times,  especially 
when  science  was  governed  by  natural  philosophy,  that  even  after  a 
piece  of  skin  had  grown  firmly  to  its  new  owner,  its  nutrition  depended 
on  the  state  of  health  of  its  original  possessor."  Fortunately,  we  now 
know  better. 

Autografts  should  be  used  in  preference  to  all  others  when  available. 
We  seldom  find  a  patient  who  cannot  supply  skin  for  one  of  the  types  of 
grafts,  and  even  if  complete  grafting  cannot  be  done  at  once,  partial 
grafting  may  be  done  and  the  work  completed  when  warranted  by  the 
condition  of  the  patient. 

Isografts. — There  is  much  difterence  of  opinion  as  to  the  advisa- 
bility of  utilizing  isografts,  and  many  surgeons  insist  that  only  auto- 
grafts should  be  used.  Of  course  autografts  are  more  likely  to  succeed, 
but  I  feel  convinced  that,  when  it  is  not  possible  to  obtain  autografts, 
isografts  are  well  worth  trying,  and  that  good  lasting  results  may  be 
secured,  if  the  grafts  are  obtained  and  transplanted  with  the  proper 

4  49 


50  PLASTIC    SURGERY 

technic.  Nevertheless,  wounds  have  come  under  my  observation  on 
which  no  isografts  would  take  (even  after  repeated  trials  from  many 
donors),  whereas  autografts  on  the  same  wounds  brought  about  prompt 
healing. 

In  the  study  of  the  series  of  550  cases  of  skin  grafting  at  the  Johns 
Hopkins  Hospital,  published  in  1909,  I  reported  40  successful  cases  of 
isografting.  These  results  were  taken  from  the  hospital  history  notes, 
but  I  do  not  now  believe  that  the  percentage  of  permanent  takes 
was  as  large  as  these  notes  had  led  me  to  believe. 

I  have  thought  for  some  time  that  the  success  or  failure  of  isografts 
may  be  dependent  on  the  similarity  or  dissimilarity  of  blood  groups  of 
the  host  and  donor.  This  point  has  been  proved  by  Masson,  at  the 
Mayo  Clinic,  who  reports  excellent  results  with  isografts,  and  has  had 
the  opportunity  of  testing  the  blood  of  the  donor  and  of  the  recipient  for 
agglutination.  He  has  never  had  a  successful  result  in  isografting  in  a 
case  in  which  the  red  blood  corpuscles  of  the  donor  were  agglutinated, 
by  the  serum  of  the  patient.  The  results  in  all  other  cases  in  which  the 
blood  did  not  agglutinate,  were  most  satisfactory.  Shawan  has  also 
reported  similar  results  in  grafting  war  wounds,  in  which  the  principle 
of  blood  grouping  was  applied.  These  findings  are  of  the  greatest  im- 
portance, inasmuch  as  by  means  of  a  simple  blood  test  the  likelihood  of 
a  successful  isografting  can  be  forecast  with  a  fair  degree  of  certainty. 

Care  must  be  taken  when  isografting  is  contemplated,  not  to  trans- 
mit disease  to  a  healthy  person,  as  cases  have  been  reported  in  which 
small-pox,  syphilis,  and  tuberculosis  have  been  transmitted  in  this 
manner. 

R.  Minervini  reported  the  successful  use  of  whole-thickness  grafts 
obtained  from  the  skin  of  babies  who  had  died  during  delivery  or  a  few 
hours  after  birth.  This  material,  if  available,  is  undoubtedly  most 
satisfactory  for  successful  transplantation. 

Isografts  may  be  obtained  in  the  operating  room  (while  performing 
any  clean  operation)  by  removing  an  elliptic-shaped  piece  of  skin, 
instead  of  making  a  linear  incision.  This  wound  can  be  closed  as  easily 
as  the  linear  incision.  Permission  to  remove  this  skin  should  always  be 
obtained  from  the  patient  in  advance,  and  all  necessary  tests  should  be 
made  to  safeguard  against  the  transmission  of  disease  to  the  patient 
to  be  grafted.  I  have  successfully  transplanted  skin  obtained  in  this 
way  in  a  number  of  cases. 

Zoografts. — Zoografting  has  been  tried  for  years,  and  successes 
have  been  reported.     The  grafts  have  been  taken  from  many  species, 


THE  TRANSPLANTATION  OF  SKIN  5 1 

among  others  from  the  inner  surface  of  the  wing  of  a  pullet,  skin  from 
pigeons,  from  young  puppies,  from  guinea-pigs,  rats  and  rabbits. 
Bartoux  and  Dubousquet-Laborderie  successfully  implanted  the  skin  of 
frogs  on  a  granulating  surface  in  man.  The  pigment  disappeared  in  10 
days,  and  the  grafts  rapidly  changed  in  character,  taking  on  more  and 
more  the  resemblance  to  human  skin.  Cannaday  grafted  with  fair 
success  the  skin  of  a  common  water  lizard. 

Bits  of  muscle  have  been  applied  to  granulating  wounds,  and  more 
rapid  epidermization  was  claimed.  The  lining  membrane  of  a  hen's 
egg,  cut  in  strips  and  applied  with  the  shell  surface  outward,  has  also 
been  used.  Riven  and  also  Browning  successfully  transplanted  the 
superficial  layers  of  the  skin  of  a  young  pig,  and  it  was  noted  that  the 
pigment  rapidly  disappeared.  Flegenheimer  transplanted  whole-thick- 
ness grafts,  with  good  results,  from  the  the  belly  of  a  young  pig  and 
stated  that  fine  hair  grew  on  the  graft. 

Venable  reported  his  studies  w4th  Ollier-Thiersch  grafts  of  pig  skin 
in  the  treatment  of  extensive  burns  and  stated  that  he  obtained  from 
85  to  100  per  cent  of  takes. 

Miles  transplanted  the  skin  of  dogs,  rabbits,  kittens  and  frogs. 
He  was  most  successful  with  grafts  from  dogs,  and  least  successful  with 
frog  skin.  A  young  animal  was  always  selected.  It  was  killed  and 
after  the  skin  of  the  abdomen  had  been  thoroughly  cleansed,  whole- 
thickness  grafts  without  the  subcutaneous  fat  were  removed.  These 
were  placed  in  sterile  boric  acid  solution,  trimmed  to  fit  the  wound,  and 
pressed  in  on  healthy  undisturbed  granulations.  He  quotes  four 
successful  cases,  and  noted  that  the  pigment  rapidly  disappeared, 
and  that  no  haij",  sweat  or  sebaceous  matter  could  be  found  in  the  skin. 

]\Iy  own  experience  is  that  these  grafts  take  readily,  and  receive  their 
blood  supply  as  promptly  as  ordinary  grafts.  They  also  have  the 
same  power  of  stimulating  epithelial  growth  from  the  edges  when 
placed  on  granulating  wounds,  as  do  other  grafts.  Nevertheless,  in 
every  case  which  has  come  under  my  observation  these  grafts,  after 
doing  well  and  often  when  the  wound  was  entirely  healed,  suddenly 
and  with  no  apparent  cause  have  begun  to  melt  away,  and  have  soon 
disappeared. 

AxAPHYLACTic  SYMPTOMS  have  been  reported  in  several  cases 
following  the  use  of  isografts,  and  egg  membrane  grafts,  but  in  a  some- 
what wide  experience  I  have  never  observed  such  symptoms. 

Sponge  grafting  was  elaborated  by  Hamilton  of  Edinburgh.  The 
granulating  wound  was  accurately  covered  with  thin  sections  of  a  fine 


52  PLASTIC    SURGERY 

sponge  previously  prepared,  and  these  sections  were  replaced  as  the 
granulations  grew.  The  wound  was  dressed  with  protective  and  wet 
carbolic  acid  (1-20)  gauze.  Healing  was  very  slow.  This  method  was 
soon  abandoned  as  an  aid  in  hastening  epithelization.  I  have  found  it 
useful  in  stimulating  sluggish  granulations,  as  is  also  the  network  of 
catgut  suggested  b}^  Neuhauser. 

Transplantation  of  Fetal  Membranes. — In  1909  and  1910  at  the 
suggestion  of  W.  L.  Thornton,  then  a  third  year  student  in  the  Johns 
Hopkins  ^Medical  School,  I  tried  grafting  pieces  of  the  lining  of  the 
amniotic  sac,  but  was  unable  to  secure  permanent  results. 

In  1913,  Sabella  and  Stern  reported  several  cases  in  which  they  had 
successfully  transplanted  amniotic  membrane.  They  were  able  to 
preser\'e  this  tissue  for  some  time  by  the  Carrel  technic  (petrolatum  and 
cold  storage; .  They  insist  upon  the  importance  of  placing  the  lining 
or  glistening  side  of  the  membrane  next  to  the  wound.  Flexible 
paraflEin,  or  moist  salt  gauze  dressings  were  used. 

Ulcers,  bums  and  traumatic  denudations  were  grafted  successfully 
with  this  material,  but  the  final  results  after  a  considerable  period  of 
time  had  elapsed  were  not  given.  Since  the  publication  of  these  reports 
little  has  been  heard  of  this  method. 

The  material  is  abundant  in  every  hospital  with  an  obstetrical  de- 
partment, and  would  therefore  be  easily  available.  Theoretically  this 
tissue  should  be  transplantable,  as  it  is  derived  from  the  ectoderm  and 
is  composed  of  embr^^onic  skin  elements.  There  is  considerable  doubt 
in  my  mind  as  to  the  permanent  results  obtainable  from  the  use  of  fetal 
membranes. 

Surface  on  Which  Grafts  May  be  Placed. — ^All  types  of  grafts  may 
be  placed  on  fresh  w^ounds  and  also  on  healthy  granulating  surfaces. 
When  the  wound  is  fresh,  the  grafts  will  live  when  placed  on  fat,  fascia, 
tendon,  muscle,  perichondrium  or  bone. 

When  placed  on  granulating  surfaces  success  depends  to  a  large 
extent  on  the  condition  of  the  wound,  and  it  is  most  important  that  the 
granulations  be  clean,  firm,  rose-pink  in  color,  and  not  exuberant.  In 
addition  the  bacterial  count  from  the  wound  secretion  should  be 
negative,  and  time  is  saved  in  the  end  by  careful  attention  to  this  point. 

The  advantages  of  placing  grafts  on  undisturbed  granulations 
are  that  (i)  there  is  no  pain  during  the  preparation  of  the  wound,  or 
application  of  the  graft,  (2)  there  is  no  loss  of  blood — an  important 
point  in  patients  already  much  depleted,  (3)  there  is  little  likelihood  of 
blood  or  serum  collecting  under  the  grafts,  (4)  there  is  no  danger  of 


THE  TRANSPLANTATION  OF  SKIN  53 

lighting  up  infection,  and  blood  vessels  enter  the  grafts  much  sooner 
if  the  granulations  are  not  removed. 

I  have  been  able  to  obtain  bleeding  by  cutting  into  a  whole  thickness 
graft  84  hours  after  transplantation  upon  a  healthy  granulating  surface, 
whereas  the  earliest  record  of  bleeding  in  a  similar  graft  on  a  fresh  wound 
is  6  days  (Krause). 

Preparation  of  the  Granulating  Area  for  Grafting. — In  order  to  put 
a  granulating  surface  into  the  proper  condition  for  grafting,  various 
methods  may  be  employed.  Among  others  may  be  mentioned  painting 
with  tincture  of  iodin,  touching  frequently  with  nitrate  of  silver  (weak 
solutions  for  stimulation,  saturated  solutions  or  stick  for  cauterization), 
applying  balsam  of  Peru  (either  pure  or  in  castor  oil,  i  to  3),  gauze  wet 
with  boric  acid,  or  salt  solution,  or  a  solution  of  chloral  hydrate  2  grains 
to  the  ounce  of  water.  I  have  found  it  ver}'  satisfactory  after  cauteriz- 
ing thoroughly  with  pure  carbolic  acid,  to  remove  the  granulations  down 
to  the  firm  base,  then  dress  with  dry  gauze  over  which  is  placed  sterile 
boric  acid  ointment.  If  this  is  done  it  will  be  found  that  within  48 
hours  the  new  granulations  will  be  ready  for  grafting. 

The  development  of  the  use  of  Dakin's  hypochlorite  solution  used 
either  by  Carrel's  technic  or  on  compresses,  for  rendering  a  granulating 
surface  sterile  is  a  great  advance  in  the  preparation  of  wounds  for 
grafting.  The  progress  of  disinfection  by  this  method  can  be  followed 
by  bacterial  counts  and  gives  us  absolute  control  as  to  the  condition  of 
the  surface.  Dichloramin-T  in  from  5.-7.5  per  cent  strength  is  also 
useful  for  the  same  purpose. 

Method  of  Preparing  Healthy  Granulations  to  Receive  Grafts. — On 
the  day  preceding  the  operation  all  secretions  and  crusts  are  removed 
and  the  granulations  are  dressed  with  moist  boric  acid  or  salt  solution 
gauze.  The  dressings  are  removed  at  the  time  of  operation  and  the 
wound  washed  carefully  so  as  not  to  cause  bleeding  with  gauze  sponges 
dipped  in  warm  salt  solution.  The  surface  is  thoroughly  dried,  a  pad 
of  dry  gauze  is  placed  over  the  wound,  pressed  down  firmly  on  the 
granulations  and  removed  only  when  the  operator  is  ready  to  apply  the 
grafts.  It  is  most  important  that  the  surface  to  be  grafted  should  be 
perfectly  dry,  because  the  grafts  adhere  much  better  to  a  dry  surface 
and  are  less  liable  to  be  subsequently  displaced.  If  Dakin's  solution 
has  been  used  in  the  preparation,  it  is  only  necessary  to  dry  the  granu- 
lating surface.  ^ 

1  R.  C.  Bryan,  in  1917,  speaking  of  the  Carrel  treatment  mth  Dakin's  solution,  says: 
"It  is  interesting  to  note  that  there  is  no  skin  grafting  done  upon  the  large  raw  surfaces. 


54  PLASTIC    SURGERY 

Anesthesia.' — All  1)^65  of  grafts  may  be  cut  under  local  anesthesia, 
either  by  infiltration  or  nerve  blocking;  the  infiltration  seems  to  have 
no  deterrent  effect  on  the  healing  of  the  grafts. 

Small  deep  grafts  are  usually  applied  to  undisturbed  granulations, 
and  general  anesthesia  is  unnecessary',  unless  the  patient  is  a  young 
child  or  is  in  a  highly  nervous  condition. 

A  general  anesthetic  is  often  necessary  in  the  extensive  operative 
procedures  resulting  in  the  fresh  wound  to  be  grafted.  Advantage  is 
always  taken  of  this  anesthetic  to  cut  the  Ollier-Thiersch  or  whole 
thickness  grafts,  which  are  the  types  ordinarily  used  to  cover  large 
fresh  wounds. 

Rose  cites  cases  in  which  he  cut  grafts  2.5  to  5.  cm.  (i  to  2  inches) 
wide  and  as  long  as  necessar}^,  without  the  use  of  an  anesthetic.  Pos- 
sibty  this  can  be  done  in  a  limited  number  of  cases.  Torrance  freezes 
the  area  to  be  cut  with  ethyl  chloride,  he  then  cuts  Ollier-Thiersch 
grafts  and  transplants  successfully.  Foote  infiltrates  small  areas  with 
salt  solution,  and  then  cuts  from  these  areas. 

I  have  cut  Ollier-Thiersch  grafts  after  freezing  or  using  the  ether 
spray  with  little  or  no  discomfort  to  the  patient. 

Xystrom  in  January.  1909,  advised  that  whole  thickness  and  Ollier- 
Thiersch  grafts  be  cut  after  anesthetizing  the  external  cutaneous  nerve 
(oi  the  thighj  through  the  skin  by  means  of  4.  or  5.  c.c.  of  a  i  per  cent 
solution  of  novocain,  to  which  was  added  5  drops  of  i  to  1000  adrenalin 
chloride  solution  for  each  10.  c.c.  This  mixture  was  injected  just  to  the 
inner  side  of  the  anterior-superior  iliac  spine,  then  below  it  at  various 
depths  in  the  subcutaneous  tissues;  some  of  the  fluid  being  deposited 
under  the  fascia  lata  but  not  too  deeply  into  the  muscles.  Blocking 
of  the  external  cutaneous  nerve  was  first  practised  at  the  Johns  Hopkins 
Hospital,  over  15  years  before  Nystrom's  report,  for  the  purpose  of 
cutting  grafts  without  pain  from  the  area  supplied  by  this  nerve,  and 
this  method  is  still  occasionally  used. 

The  area  from  ^^^IICH  the  grafts  are  to  be  cut  may  be  prepared 
as  for  any  other  operation. 


Although  grafting  at  first  would  apparently  hasten  recovery,  by  mathematical  equation 
it  has  been  demonstrated  to  delay  repair,  so  that  the  surgeons  have  found  out  by  experience 
that  the  application  of  skin  was  unnecessary,  and  in  every  instance  was  contraindicated." 
Evidently  this  viewpoint  has  changed,  since  at  the  Rockefeller  War  Demonstration 
Hospital,  every  surface  wound  of  any  size  that  has  been  rendered  aseptic  by  Carrel's  technic 
with  Dakin's  solution,  is  skin  grafted,  and  by  this  means  the  time  of  healing  is  very  much 
shortened. 


THE  TRANSPLANTATION  OF  SKIN 


5D 


Dressing  of  the  Area  From  Which  the  Graft  is  Cut. — All  sorts  of 
dressings  have  been  tried.  Sterile  boric-acid  ointment  spread  on  rubber 
protective,  or  silver  foil  covered  with  rubber  protective,  are  com- 
fortable and  efficient  for  the  wounds  resulting  from  the  cutting  of  small 
deep  grafts  and  Ollier-Thiersch  grafts.  Both  of  these  dressings  should 
extend  some  distance  beyond  the  margins  of  the  wound,  and  be  held  in 
place  with  strips  of  adhesive  plaster,  over  which  is  placed  dry  sterile 
gauze  and  a  bandage.  One  of  the  flexible  parathn  mixtures,  applied 
as  to  a  burn,  is  also  satisfactory. 

The  wound  from  which  a  graft  of  whole-thickness  skin  is  taken 
should  be  dressed  as  any  ordinary  sutured  wound. 

SM.AXL  DEEP  SKIX  GRAFTS 

The  hastening  of  the  healing  of  granulating  wounds  by  the  use  of 
small  detached  bits  of  skin  was  iirst  demonstrated  by  J.-L.  Reverdin. 

Grafts  obtained  by  Reverdin's  method  are  usually  thought  of  as  pure 
epidermic  grafts,  and  in  his  articles  Reverdin  always  spoke  of  them  as 
grejfe  epidermique;  but  in  his  exhaustive  paper  on  the  subject  published 
in  1872.  he  says  in  part,  ''The  title  'epidermic'  grafts  is  not  absolutely 
correct,  as  the  transplanted  bit  is  composed  of  the  whole  epidermis,  and 
a  very  little  of  the  dermis." 

Reverdin  also  said  that  if  the  epidermis  alone  could  be  transplanted 
the  same  result  would  be  obtained  as  when  a  part  of  the  dermis  was 
included.  This,  of  course,  is  true  in  so  far  as  the  epithelium  is  con- 
cerned, but  it  has  been  my  experience  in  a  large  number  of  cases  that 
the  grafts  which  are  somewhat  deeper  and  contain  more  of  the  true 
skin,  give  a  more  stable  healing,  and  that  the  final  result  shows  more  of 
the  normal  skin-characteristics  than  when  the  thinner  grafts  are  used. 
I  have  called  these  grafts  small  deep  grafts  (Fig.  65). 

As  there  is  little  difference  except  in  thickness  between  the  small 
deep  grafts  and  Reverdin  grafts,  the  following  methods  of  prepara- 
tion will  be  found  applicable  for  either  type. 

Autografts  are  almost  uniformly  successful  when  placed  on  a  granu- 
lating surface  that  is  in  proper  condition.  It  is  far  easier  to  cut  them 
from  a  region  such  as  the  front  of  the  thigh  where  the  skin  is  quite  taut, 
than  from  places  where  it  is  lax,  as  for  instance  on  the  abdomen. 

A  large  number  of  these  grafts  can  be  obtained  from  a  comparatively 
small  area,  thus  making  it  possible  to  use  small  grafts  on  extensive 


50  PLASTIC    SURGERY 

wounds  without  any  severe  tax  on  an  ill  patient.-^  In  a  number  of 
instances  I  have  applied  several  hundred  of  these  grafts  at  a  single 
operation. 

Technic. — The  simplest  way  to  obtain  these  grafts  is  to  pick  up  a  bit 
of  the  epidermis  with  a  straight  intestinal  needle  held  in  an  artery 
clamp.  ^     It  is  raised  so  that  a  little  cone  is  formed  and  the  base  of  the 


Fig.  65. — Photomicrographs  of  the  same  magnification  showing  the  comparative  thickness 
of  a  small  deep  graft  and  a  Reverdin  graft. 

A.  A  small  deep  graft  cut  to  include  a  considerable  thickness  of  the  true  skin;  in  the 
section  the  edges  of  the  graft  are  curled  inward. 

B.  A  Reverdin  graft  cut  to  include  as  Httle  of  the  dermis  as  possible;   there  is  a  thin 
layer  of  the  dermis  throughout,  which  is  thickest  in  the  center. 


cone  is  cut  through  by  depressing  the  blade  of  the  knife. ^  (The  thinner 
Reverdin  grafts  may  be  obtained  by  cutting  oflf  the  tip  of  the  cone). 
The  graft,  still  on  the  needle,  is  transferred  to  the  wound  with  the  raw 
surface  downward  fFig.  66j.     The  grafts  are  placed  in  rows,  a  space 

'■  I  have  in  mind  an  illustrative  case.  A  child,  aged  12,  was  severely  burned  over  the 
pelvis,  thighs  and  legs.  She  came  under  my  care  nearly  a  year  after  the  accident,  during 
which  period  she  had  been  repeatedly  grafted  without  success.  Her  condition  was  des- 
perate. She  was  delirious,  extremely  emaciated  and  generally  depleted  by  the  pain  and 
by  the  long-standing  suppurating  wounds.  As  a  last  resort  the  wounds  were  grafted  with 
small  deep  autografts,  which  were  successful,  and  within  a  few  days  the  change  in  her 
condition  for  the  better  was  astonishing.  A  prompt  recovery  followed.  No  other  type 
of  autograft  could  have  been  successful  in  this  case,  on  account  of  the  condition  of  the 
granulations. 

^  Agnew,  D.  H.,  first  suggested  the  use  of  the  needle  to  raise  the  bit  of  skin  to  be  cut  in 
obtaining  Reverdin  grafts. 

'  The  use  of  forceps  and  scissors  in  obtaining  small  grafts  is  not  desirable,  as  the  skin  is 
thereby  traumatized  unnecessarily. 


THE  TRANSPLANTATION  OF  SKIN 


57 


of  0.5  cm.  ( '  5  inch)  being  left  between  each  graft.'  When  two  rows  are 
in  place  a  strip  of  dry  sterile  rubber  protective,  about  2.5  cm.  (i  inch) 
wide,  in  which  V-shaped  cuts  have  been  made,  is  applied  over  them,  so 
that  the  lower  edge  of  the  protective  just  covers  the  row  of  grafts  last 
applied.  Then  the  protective  is  pressed  down  over  the  grafts  firmly 
with  a  gauze  pledget  and  the  edges  of  the  grafts  will  uncurl  and  spread  out 
evenly  on  the  wound.  The  next  row  of  grafts  is  placed  close  to  the  edge 
of  the  protective,  and  after  two  or  three  rows  have  been  applied  they  are 
covered  with  a  second  strip  of  protective,  which  overlaps  the  first  piece 


Fig.  66. — Method  of  cutting  Reverdin  and  small  deep  grafts. 

1.  A  straight  intestinal  needle,  held  in  an  artery  clamp,  with  its  point  engaged  in  the 
skin.      A  little  cone  of  skin  is  raised. 

2.  The  scalpel  cutting  through  the  base  of  the  cone. 

3.  Placing  the  graft  on  the  granulating  surface.  A  large  opened-out  safety  pin  is  very 
useful  in  detaching  the  grafts  from  the  needle.  In  this  photograph  none  of  the  grafts  have 
been  pressed  down  on  the  wound,  and  the  edges  are  still  curled  under. 


about  one-half  its  width.  The  protective  is  pressed  down  firmly,  and 
the  procedure  is  continued  in  this  manner  until  the  whole  wound,  or 
the  part  selected,  is  covered.-  The  ends  of  the  protective  strips  which 
extend  beyond  the  wound  edges  may  be  fastened  securely  to  the  normal 
skin  with  a  few  drops  of  chloroform.  Moist  salt  solution  gauze  over 
the  protective  strips  secured  by  a  bandage  aft'ords  a  satisfactory  dress- 
ing.^    Paraffined  mosquito  netting  immediately  over  the  grafts,  and 

1  The  grafts  will  spread  over  a  considerably  larger  area,  but  I  believe  that  more  stable 
healing  is  produced  when  the  grafts  are  placed  quite  close  together,  than  when  they  are 
placed  with  greater  intervals  between. 

-  The  overlapping  strips  of  protective  and  the  V-shaped  cuts  allow  the  escape  of  any 
secretions  from  the  wound  into  the  overlying  dressings. 

'  C.  A.  Porter  of  Boston  uses  crepe  lisse  and  collodion  to  hold  grafts  on  small  wounds. 


58 


PLASTIC  SURGERY 


then  boric-acid  ointment  is  also  a  useful  dressing.     The  part  should  be 
immobilized  as  far  as  possible. 

The  grafts  are  either  round  or  irregularly  oval.  They  vary  between 
0.2  and  0.4  cm.  f about  ^'{2  and  ^i  inch)  in  diameter,  and  should  seldom 
be  larger  than  0.4  cm.  (about  y^  inch).  They  are  thickest  in  the  center 
and  taper  off  toward  the  edges.  With  a  sharp  knife  the  size,  contour 
and  depth  can  be  judged  quite  accurately  (Fig.  67). 


<§§^} 


-•^- 


Fig.  67. — I.  The  actual  size  of  a  small  deep  graft  with  its  edges  curled  under.  When 
this  graft  is  pressed  down  on  a  wound  the  edges  flatten  out,  thus  making  the  graft  about 
one-third  larger. 

2.  The  punched  out  defects  left  after  cutting  the  grafts.  Some  are  filling  up  with 
blood  in  spite  of  the  epinephrin  in  the  local  anesthetic.  Note  the  depth  of  the  pits  and  the 
rim  of  undisturbed  skin  between  them. 


The  wounds  left  by  the  removal  of  the  grafts  have  the  appearance 
of  small  pits  punched  in  the  skin,  there  being  a  rim  of  untouched  epi- 
thelium between  the  pits.  Fat  may  be  seen  in  the  bottom  of  some  of  the 
pits,  which  shows  that  a  considerable  depth  of  the  skin  is  used. 

There  is  more  bleeding  following  the  removal  of  these  small  deep 
grafts  than  when  the  Reverdin  grafts  are  cut,  and  the  resulting  scars 
are  also  somewhat  more  pronounced. 


THE  TRANSPLAXTATIOX  OF  SKIX 


59 


Sometimes  when  the  grafts  are  small  and  the  skin  blood-stained,  it 
is  difficult  to  determine  which  is  the  raw  surface.  This  difficulty  is 
obviated  when  the  grafts  are  obtained  from  a  negro  or  when  the  iodin 
technic  is  employed. 

When  a  large  number  of  these  grafts  are  necessary  the  process  is 
very  tedious,  but  this  may  be  mitigated  to  a  certain  extent  by  having 
two  men  to  cut  the  grafts,  while  a  third  places  them,  or  vice  versa, 
depending  upon  conditions. 

A  Rack  for  Facilitatixg  the  Haxdlixg  of  Small  Deep  Skix 
Grafts.— -As  a  rule  there  are  no  conveniences  for  stacking  the  arterv 


Fig.  68. — Rack  for  facilitating  the  handling  of  small  deep  skin  grafts.  In  the  illustra- 
tion the  rack  is  tilted  in  order  to  show  each  slot.  Xote  the  dimensions.  The  rack  is  filled 
with  Halsted  clamps,  each  carrying  a  straight  intestinal  needle.  The  handles  of  the  clamps 
are  on  the  highest  side  of  the  rack.  The  slope  is  sufficient  to  prevent  them  from  sliding, 
and  thus  brushing  off  the  grafts,  which  can  be  seen  on  each  needle. 

clamps  that  hold  the  needles  and  grafts.  In  consequence  an  instru- 
ment is  often  upset  or  slips,  the  graft  is  brushed  off,  and  is  lost  or  much 
time  is  wasted  in  trying  to  pick  it  up.  In  order  to  eliminate  this  in- 
convenience I  have  devised  a  slotted  metal  rack  to  hold  the  clamps. 
It  is  made  of  i8-gage  sheet  copper,  so  bent  that  the  end  view  shows  the 
form  of  a  trapezium.  The  longest  side  of  this  figure  is  used  as  the  base, 
and  to  facihtate  cleaning  is  open,  except  for  three  strips  which  are 
necessary  to  brace  it.  The  twelve  slots  are  made  on  the  side  opposite 
the  base,  and  each  is  wide  enough  to  admit  the  ordinary  Halsted  artery 
clamp  (Fig.  68). 


6o  PLASTIC  SURGERY 

The  rack  can  be  used  with  great  comfort  when  one  man  is  cutting 
and  also  placing  the  grafts.  The  twelve  slots  are  filled,  the  rack  is  then 
moved  close  to  the  wound  to  be  grafted,  and  all  these  grafts  are  then 
applied.  This  maneuver  can  be  repeated  as  often  as  necessary,  and 
it  can  be  readily  seen  that  an  enormous  amount  of  labor  is  saved,  as 
without  this  frame  each  graft  would  have  to  be  placed  on  the  wound  as 
it  was  cut. 

When  a  large  wound  is  being  grafted  with  small  deep  grafts,  the 
method  of  procedure  is  as  follows — The  rack,  with  its  highest  side 
toward  the  operator,  is  placed  in  a  position  convenient  for  him.  Then 
as  the  grafts  are  cut  the  clamps  are  dropped  into  the  slots,  and  when 
the  cutting  is  faster  than  the  placing,  the  clamps  are  moved  along  pro- 
gressively toward  the  placer,  by  the  nurse,  so  that  those  grafts  first 
cut  will  be  applied  first. 

Post-operative  Treatment. — ^As  a  rule  the  patient  should  ordina- 
rily be  kept  in  bed  for  a  longer  or  shorter  period,  depending  on  the  size 
and  location  of  the  grafted  area.  Nevertheless,  I  have  had  considerable 
success  in  grafting  ulcers  in  the  Out-patient  Department  with  small 
deep  grafts  and  have  allowed  the  patients  to  go  about  their  business. 

The  part  should  be  immobilized  and  protected  from  injury,  If 
the  grafts  have  been  placed  on  a  granulating  surface  the  dressings 
should  be  removed  not  later  than  the  second  or  third  day  and  any  wound 
secretions  carefully  mopped  or  washed  off  with  a  gentle  irrigation  of 
normal  salt  solution.  If  the  grafts  are  placed  on  a  fresh  wound  the 
first  dressing  may  be  delayed  until  the  fifth  or  sixth  day  (Fig.  69). 

It  is  possible  after  48  hours  to  tell  whether  or  not  the  grafts  have 
been  successful,  and  in  many  instances  a  narrow  ring  of  new  epithelial 
growth  can  be  seen  surrounding  each  graft.  Should  the  granulations 
between  the  grafts  be  unhealthy,  compresses  wet  with  Dakin's  solution 
may  be  employed  without  injury  after  the  fourth  day,  but  I  do  not 
believe  that  the  grafts  spread  as  rapidly  as  when  milder  measures  are 
used.  My  experience  has  been  that  this  solution  is  injurious  before 
the  blood  supply  to  the  grafts  is  assured. 

Later  some  bland  ointment  on  old  linen  is  applied,  and  if  after  a  day 
or  two  the  epithelial  growth  from  the  grafts  is  not  as  vigorous  as  desired, 
it  is  well  to  alternate  the  bland  ointment  with  scarlet  red  (8  per  cent, 
in  either  petrolatum,  or  in  zinc  ointment)  or  to  use  some  other  epithelial 
stimulant. 

The  surface  from  which  the  grafts  are  taken  should  be  dressed  in 
three  or  four  days  if  protective  or  paraffin  is  used  and  the  area  dusted 


THE  TRANSPLANTATION  OF  SKIN 


6i 


with  a  dry  powder.  If  silver  foil  is  used,  it  should  not  be  disturbed  for 
ten  days,  but  after  this  time  all  dressings  may  ordinarily  be  removed. 

As  soon  as  the  new  epithelium  has  filled  the  gaps  between  the  grafts 
and  joined  the  epithelium  from  the  wound  edges,  the  grafted  area  may 
be  dressed  with  a  dry  powder,  such  as  zinc  stearate,  and  exposed  to 
the  air.  I  have  not  found  the  open  treatment  of  these  or  any  other 
grafts  immediately  after  application  to  be  satisfactory;  although  ex- 
posure for  an  hour  or  two  at  a  time,  to  the  light  and  air  is  advantageous 
after  the  second  or  third  day. 

The  grafted  area  should  be  protected  from  injury  for  several  weeks. 
Gentle  massage  is  advisable  after  about  three  weeks,  and  should  be 


Fig.  69. — Small  deep  grafts. 

1.  A  portion  of  a  granulating  wound  ten  days  after  grafting  with  small  deep  grafts. 
Note  the  grafts  in  the  center  of  a  halo  of  new  epithelium,  which  is  spreading  around  each 
one  of  them.     Some  have  already  joined. 

2.  The  same  area  two  months  later.  The  grafts  themselves  are  of  normal-appearing 
skin,  which  is  soft  and  flexible.     Between  the  grafts  is  scar  tissue  which  is  slightly  depressed. 

continued  until  the  grafted  area  is  as  freely  movable  as  the  normal  skin 
around  it. 

There  is  marked  desquamation  of  the  grafted  surface  when  it  dries 
out,  especially  between  the  grafts,  which  is  evidently  due  to  epithelial 
over-production,  but  this  scaliness  can  easily  be  controlled  by  the  appli- 
cation of  olive  oil,  or  cocoa  butter. 

Untoward  Possibilities. — There  are  certain  untoward  possibilities 
which  must  be  considered.  On  account  of  the  simplicity  of  the 
operative  procedure,  we  are  accustomed  to  regard  the  use  of  small  grafts 
as  attended  with  no  danger  and  with  but  few  bad  results.  Aside  from 
contraction,  which  may  occur,  we  must  consider  the  danger  of  carrying 


62 


PLASTIC  SURGERY 


infection  from  the  granulating  surface  to  the  wounds  from  which  the 
grafts  are  cut.     It  is  a  difficult  matter  to  convey  a  graft  on  a  needle  or 


1234 

Pig.    70. — Chronic  ulcer  of  the  groin,  following  the  excision  of  tubercular  (?)  glands. 

Duration  two  years. 

1.  Note  the  position  of  the  ulcer  and  the  scar  above  it,  as  the  ulcer  gradually  healed 
above  and  extended  below. 

2.  The  same  ulcer  eight  months  later,  after  excision  with  the  cautery.  Note  the 
position,  now  on  the  level  with  the  anus,  healing  having  taken  place  above. 

3.  Ulcer  on  the  thigh  following  an  infection  from  the  parent  ulcer  in  the  area  from  which 
small  deep  grafts  were  removed. 

4.  The  scar  following  healing  of  the  ulcer  shown  in  i  and  2.  This  was  finally  accom- 
plished by  frequent  excisions  with  the  cautery  and  numerous  graftings.  This  photograph 
was  taken  just  one  year  after  the  first  picture  in  this  group. 

None  of  the  tests  tried  revealed  the  cause  of  the  great  resistance  of  this  ulcer  to  treat- 
ment. There  has  been  no  recurrence  during  the  six  years  which  have  elapsed  since  dis- 
charge from  the  hospital. 


Fig.  71. — Result  of  small  deep  grafting  on  a  third-degree  burn  of  the  forearm  and  wrist 
of  a  negro  woman.  The  grafts  can  be  seen  in  little  pits  surrounded  by  a  keloid-like  growth. 
The  tendency  to  contracture  in  this  situation  is  quite  marked  and  a  profile  view  shows 
flexion  of  the  wrist.  The  advisability  of  using  small  deep  grafts  on  an  ulcer  of  this  extent 
and  in  this  situation  on  a  negro  is  very  questionable. 


any  other  instrument,  to  a  granulating  wound  without  occasionally 
touching  the  granulations  with  the  instrument.  In  order  to  avoid  this 
chance  of  contamination,  it  is  best  either  to  use  a  fresh  needle  for  each 


THE  TRANSPLANTATION  OF  SKIN 


63 


graft  or  to  have  several  needles,  so  that  one  can  be  flamed  while  the 
other  is  in  use^  (Fig.  70). 

Another  disagreeable  occurrence  is  the  formation  of  keloid.  Occa- 
sionally a  massive  keloid  will  form  in  the  grafted  area,  and  the  grafts 
themselves  can  be  seen  at  the  bottom  of  little  depressions  in  the  keloid 
(Fig.  71).     This  growth  would  probably  occur  in  these  wounds  whether 


Fig.  72. — Small  deep  grafts.  The  development  of  keloid  on  the  thigh  in  the  wounds 
from  which  small  deep  grafts  were  cut.  All  of  the  grafts  taken  from  the  right  thigh  were 
cut  at  one  operation  and  all  on  the  left  thigh  were  cut  at  another  time.  The  size  of  the 
grafts  taken  from  the  right  thigh  are  more  nearly  correct  (although  considerably  larger  than 
necessary)  than  those  from  the  left,  which  are  much  too  large. 

they  were  grafted  or  not.     Again,  keloid  may  develop  in  the  scars  of  the 
wounds  from  which  the  grafts  are  taken  (Fig.  72). 

Comments. — The  age  of  the  patient  has  apparently  little  effect  on 
the  healing  of  small  grafts  which  will  often  succeed  on  granulating 

^  The  importance  of  this  point  was  impressed  on  me  by  the  following  incident :  A  very 
resistant  ulcer  of  the  groin  of  long  standing,  the  etiology  of  which  could  not  be  definitely 
determined,  was  grafted  with  small  grafts  during  my  absence.  The  wounds  from  which 
the  grafts  were  taken  on  the  thigh  became  infected,  and  when  I  was  called  to  see  the  patient 
a  week  afterward,  an  ulcer  similar  to  that  in  the  groin  had  developed.  This  ulcer  also 
resisted  every  method  of  treatment  used,  and  it  was  finally  necessary  to  e.xcise  the  entire 
area  with  a  liberal  margin.  The  defect,  which  was  11  cm.  (4^5  in.)  in  diameter,  and  down 
to  the  deep  fascia,  was  immediatel}-  grafted  with  an  Ollier-Thiersch  graft  and  healed 
promptly. 


64 


PLASTIC  SURGERY 


surfaces  under  conditions  in  which  no  other  type  of  graft  could  live. 
There  is  almost  invariably  a  marked  stimulation  of  the  epithelium  of 
the  wound  edges,  following  the  application  of  these  grafts,  even  though 
the  grafts  be  unsuccessful,  and  successive  grafts  give  successive  stimula- 


PiG.    73. — Ulcer    of    the    buttock,    thigh    and    leg    following    a  burn.      Duration  thirteen 

months. 

I  and  2.  Condition  when  the  child  came  under  my  care.  Note  the  partial  contracture 
of  the  knee.  After  preparing  the  granulations  the  wounds  were  entirely  healed  four  weeks 
after  grafting  with  small  deep  grafts.  The  knee  was  then  straightened  by  a  plastic 
operation. 

3.  Photograph  taken  eighteen  months  later.  The  scar  is  soft  and  movable  and  there 
is  no  tendency  to  recontracture.      Function  of  the  part  is  perfect. 

tion.  Under  favorable  conditions  epithelium  from  a  single  graft  0.4  cm. 
(about  y-Q  inch)  in  diameter  will  spread  over  an  area  2.5  cm.  (i  inch) 
in  diameter,  but  a  more  stable  healing  follows  if  the  grafts  are  placed 
much  closer  together  (0.5  cm.  =3^:5  inch). 

The  shrinkage  in  the  size  of  the  wound  after  grafting  with  small 


THE  TRANSPLANTATION  OF  SKIN  6$ 

grafts  is  in  some  cases  quite  remarkable.  Contracture  may  occur 
under  a  grafted  area,  but  it  is  not  nearly  so  likely  as  when  grafting  is  not 
done.  If  the  grafts  are  placed  close  together  contraction  may  be  to  a 
large  extent  prevented.  Healing  is  much  expedited  by  the  use  of  these 
grafts  and  the  resulting  cicatrix  is  solid  and  resistant  (Fig.  73) . 

Small  deep  grafts  are  apparently  not  replaced  by  scar  tissue,  as 
they  can  be  demonstrated  as  definite  areas  of  normal-appearing  skin 
(sometimes  hair-bearing),  surrounded  by  scar  tissue  even  after  several 
years  have  elapsed. 

A  wound  grafted  with  these  small  grafts,  placed  at  intervals,  has  a 
dotted  appearance,  and  the  cosmetic  result  is  not  so  satisfactory  as  when 
large  Ollier-Thiersch,  or  when  whole-thickness  grafts  are  used.  For  this 
reason  it  is  better  not  to  use  them  on  the  face  unless  there  is  some  special 
reason.  The  scars  left  by  the  removal  of  these  grafts  are  after  a  time 
scarcely  noticeable,  except  in  those  instances  in  which  pigmentation 
or  keloid  occur. 

The  sensation  of  an  area  grafted  with  small  deep  grafts,  gradually 
comes  in  from  the  periphery',  and  not  from  the  underlying  tissues. 

The  above-described  procedure  is  by  far  the  simplest  method  of 
grafting.  It  requires  little  preliminary  preparation  after  the  granula- 
tions are  in  condition,  and  unless  the  area  to  be  grafted  is  large,  it  can 
be  done  in  the  patient's  room.  Enough  autografts  can  be  obtained  from 
a  small  area  to  cover  a  large  wound  without  causing  any  appreciable 
injury  to  a  patient  already  in  a  serious  condition. 

A  number  of  patients  have  come  under  my  care  whose  lives  have 
undoubtedly  been  saved  by  the  successful  use  of  these  small  grafts. 

The  difference  in  the  ultimate  result  betv,-een  small  superficial 
(Reverdin)  grafts  and  small  deep  grafts  placed  close  together  (0.5 
cm.  =  3^^  inch)  is  almost  as  marked  as  the  difi'erence  in  results  between 
those  from  Ollier-Thiersch  grafts  and  whole-thickness  grafts. 

OLLIER-THIERSCH  GRAFTS 

Ollier-Thiersch  grafts  are  those  most  generally  used  and  are  of 
enormous  size  in   comparison  with  those  advocated  by  Reverdin. 

The  method  used  in  Dr.  Halsted's  clinic  at  the  Johns  Hopkins 
Hospital  for  Ollier-Thiersch  grafting  is  simple,  satisfactory,  and  with 
some  slight  modifications  is  as  follows : 

Source  of  Grafts  and  Area  from  Which  They  are  Obtained.^The 
grafts  are  almost  always  cut  from  the  thigh  and  usually  from  the  right 


66 


PLASTIC  SURGERY 


when  practicable,  as  phlebitis  has  occasionally  developed  after  Ollier- 
Thiersch  grafts  have  been  cut  from  the  left.  The  anterior  and  inner 
portion  is  the  first  choice;  the  external  aspect  next,  and  finally,  if  neces- 
sary, the  posterior  portion.  Occasionally  the  skin  from  the  arm  or  leg 
is  used. 


Fig. 


74- — The  boards   in   place   holding   the   skin   of   the  thigh  flat  and  taut.      The  ec 
of  the  Catlin  knife  is  engaged  in  the  skin.      (Photograph  by  Schapiro.) 


Technic. — Place  a  small  sand  bag  beneath  the  thigh  for  support  in 
order  to  give  a  better  surface  from  which  to  cut.^  Arrange  the  usual 
sterile  dressing  about  the  selected  area.  Care  must  be  taken  that  no 
carbolic  or  bichloride  solutions  be  brought  into  the  field,  or  be  allowed 
to  touch  the  grafts  through  the  medium  of  the  dressings,  gloves,  or 
instruments. 

^  See  Technic  of  Skin  Preparation. 


THE  TRANSPLANTATION  OF  SKIN 


67 


Firm  traction  is  exerted  on  the  limb.  The  skin,  wet  with  salt 
solution,  is  then  put  on  the  stretch,  and  held  as  flat  as  possible  by  means 
of  two  sterile  boards  about  20.  cm.  (8  inches)  long  placed  quite  close  to- 
gether at  right  angles  to  the  length  of  the  limb,  the  first  being  held  bv  the 


Fig.  75. — The  cutting  is  nearly  completed.  The  graft  is  being  held  up  by  an  instru- 
ment. Note  the  punctate  bleeding  from  the  tops  of  the  papillae  of  the  corium.  (Photograph 
by  Schapiro.) 


assistant,  and  the  other  by  the  left  hand  of  the  operator.     Parker 

suggests  smearing  the  skin  and  knife  with  a  thin  film  of  sterile  vaselin. 

The  edge  of  the  thin  sharp  Catlin  knife^  is  then  engaged  in  the  skin 

between  these  boards,  and  held  almost  flat  against  the  limb,  and  by  a 

1 1  have  found  a  single-edged  blade  broader  and  thinner  than  the  Catlin  more  satisfac- 
tory with  these  boards,  and  use  in  my  work  either  Rehns  or  Hofifmann's  knife  without  the 
safetv  guard. 


68 


PLASTIC  SURGERY 


sawing  motion  the  graft  is  cut,  the  knife  closely  following  the  board  in 
the  hand  of  the  operator  which  is  drawn  slowly  along  in  front  of  it 
(Fig.  74) .  The  entire  area  being  constantly  kept  wet  with  salt  solution. 
If  iodin  technic  is  used  the  grafts  may  be  cut  dry.  The  graft  should 
be  cut  at  a  level  which  will  include  the  top  of  the  papillary  layer  of  the 


Fig.  76. — The  area  from  which  this  small  graft  was  cut.  The  graft  is  being  spread  out 
on  rubber  protective,  raw  surface  upward.  By  this  method  single  grafts  the  full  length  of 
the  thigh,  and  from  7.5  cm.  to  12.5  cm.  (3  to  5  inches)  wide  may  be  secured  without  diffi- 
culty. A  single  large  graft  will  heal  as  promptly  as  several  smaller  ones,  and  should  always 
be  utilized  when  possible,  as  there  is  less  scarring  when  one  graft  is  used. 

corium  and  if  properly  cut  only  a  slight  amount  of  punctate  bleeding 
will  follow  (Fig.  75). 

After  the  graft  has  been  cut,  it  is  placed  with  the  raw  surface  upper- 
most upon  a  piece  of  sterile  rubber  protective  on  a  board,  and  by  means 
of  a  smooth  instrument  the  graft  is  spread  out  evenly  on  the  protective. 


THE  TRANSPLANTATION  OF  SKIN  69 

It  is  then  covered  with  gauze  wet  in  salt  solution  until  the  area  to 
be  grafted  is  ready  (Fig.  76). 

Application  of  the  Graft. — After  all  hemorrhage  has  been 
checked  the  protective  on  which  the  graft  is  spread  is  placed  over 
the  defect  so  that  the  raw  surface  of  the  graft  is  next  to  the  wound. 
Then  the  protective  is  lifted  up  on  one  side,  the  graft  is  gradually  sepa- 
rated from  it  and  is  left  on  the  defect.  It  is  pressed  down  evenly  on 
the  wound  with  pledgets  of  gauze  to  make  it  adhere  as  closely  as  possible. 

In  every  Ollier-Thiersch  graft  over  2.  cm.  {%  inch)  in  diameter, 
V-shaped  slits  should  be  made  here  and  there  to  allow  the  escape  of 
secretions  and  air  bubbles.  Occasionally  several  fine  silk  stitches 
are  used  to  secure  the  graft  in  place.  More  especially  when  a  deep 
fold  is  grafted,  a  stitch  at  the  bottom  will  often  aid  in  securing  immobili- 
zation. Should  more  than  one  graft  be  needed,  they  are  placed  so 
that  they  slightly  overlap  the  edges  of  the  wound  and  the  adjacent 
grafts. 

By  the  method  above  described  the  largest  and  most  satisfactory 
grafts  can  be  cut,  but  this  requires  a  skilful  hand  and  constant  practice. 

Accurate  placing  of  the  grafts  minimizes  the  scar  and  thus  prevents 
to  a  certain  extent  secondary  contracture.  Immobilization  of  the  part 
after  grafting  is  important. 

Dressing  of  the  Gr.a.fted  Surface. — The  dressing  varies  accord- 
ing to  circumstances.  I  sometimes  use  perforated  or  overlapping  strips 
of  rubber  protective  next  to  the  graft,  and  over  this  gauze  saturated 
with  sterile  normal  salt  solution.  Dry  gauze  is  sometimes  placed  directly 
over  the  overlapping  protective  strips,  or  directly  over  the  graft.  Some 
prefer  alternating  wet  and  dry  dressings,  whereas  others  use  dr}'  powders 
or  ointments.  If  protective  is  used  and  the  grafts  have  been  placed  on 
a  granulating  surface,  the  first  dressing  should  be  done  within  48  hours; 
if  on  a  fresh  wound,  4  or  5  days  may  elapse  before  the  dressing  is 
changed. 

Sterile  silver  foil  is  an  excellent  dressing  for  Ollier-Thiersch  grafts. 
It  is  put  on  in  several  layers  and  over  this  is  placed  the  porous  paper 
which  separates  the  silver  leaves.  This  dressing,  theoretically,  allows 
the  secretions  to  come  through  and  be  absorbed  by  the  gauze  which 
is  placed  above  it,  but  the  paper,  especially  if  it  is  wet  with  alcohol, 
will  often  form  an  impervious  crust.  The  dressing  is  secured  by  a 
bandage  and  the  part  immobilized.  The  first  dressing  should  be  done 
ten  days  later. 

What  seems  to  be  a  failure  at  the  first  dressing  will  sometimes  turn 


70 


PLASTIC  SURGERY 


out  very  well,  and  vice  versa.  Some  grafts  are  moist,  and  there  is  a 
good  deal  of  secretion  throughout  the  healing  process,  whereas  others 
are  perfectly  dry.  In  the  moist  variety  a  strong  characteristic  glue-like 
odor  is  often  noticed. 

Too  much  pressure  on  the  dressing  over  the  grafted  area  may  cause 
sloughing  of  the  freshly  applied  graft,  and  heavy  dressings  causing 
too  much  heat  and  sweating  are  to  be  avoided.  In  the  majority  of 
cases  the  wound  caused  by  the  cutting  of  the  graft  is  healed  some  time 
before  the  patient  is  ready  to  leave  the  hospital  (Fig.  77). 

After  using  several  of  the  flexible  paraffin  mixtures  as  primary 
dressings  on  Ollier-Thiersch  grafts,  I  am  not  enthusiastic  about  paraffin 


Pig.   77.- 


-Scar   on   outer   side   of   thigh   due   to   removal  of  a  large  Ollier-Thiersch  graft. 
Photograph  taken  five  weeks  after  operation. 


for  this  purpose.  If  it  is  employed,  the  dressings  should  be  changed 
every  day.  Paraffin  is  much  more  satisfactory  as  a  later  dressing,  but 
care  should  be  taken  not  to  apply  it  too  hot. 

Mayer  makes  a  sort  of  cage  by  putting  a  ring  of  sterile  gauze  around 
the  limb  above  and  below  the  wound;  resting  on  these  rings  little 
strips  of  sterile  wood  are  laid,  and  over  this  is  placed  the  wet  dressing, 
thus  making  a  moist  chamber  and  preventing  pressure  on  the  newly 
grafted  area.     This  is  an  excellent  method  in  selected  cases. 

Briining  advocates  leaving  the  grafts  exposed  to  the  open  air.     He 


THE  TRANSPLANTATION  OF  SKIN 


71 


Fig.  78. — Front  and  lateral  views  of  small  cages  made  of  woven  wire.  They  are  bound 
with  adhesive  plaster  and  are  padded  with  felt.  Similar  cages  may  be  made  to  fit  almost 
any  region,  and  may  be  either  very  small  or  of  considerable  size.  The  completed  cage  may 
be  wrapped  and  sterilized  with  the  other  dressings. 


Fig.    79. — A   wire  cage  large   enough   to   protect   the   chest  and  abdomen, 
the  cage  rest  on  a  Bradford  frame. 


The  edges  of 


72  PLASTIC  SURGERY 

claims  that  absence  of  dressings  prevents  displacement  of  the  grafts, 
that  the  grafts  heal  within  eight  days  and  there  is  no  subsequent  shrink- 
age. He  also  says  that  any  collection  of  serum  under  the  grafts  can  be 
quickly  noticed  and  easily  pressed  out. 

Goldman  holds  that  inasmuch  as  in  the  open  method  the  chief 
object  being  secure  fixation,  and  that  as  this  occurs  within  the  first 
24  hours,  exposure  to  the  air  affords  the  most  efficient  treatment,  be- 
cause it  dries  the  cementing  substance.  Laplace  also  obtains  good 
results  from  the  open  method  after  grafting  on  healthy  granulations. 
Bernhard  grafts  on  healthy  granulations  and  exposes  the  grafted  area 
immediately  to  the  sunshine.  He  says  it  dries  and  is  stimulated  to 
heal  best  by  this  treatment.  Weischer  and  others  claim  that  the  results 
with  the  open  method  are  not  satisfactory. 

My  own  experience  has  been  quite  favorable  when  the  grafts  have 
been  exposed  to  the  open  air  after  a  few  days  have  elapsed,  but  not 
immediately  after  grafting.  Exposure  to  the  air  is  much  facilitated 
by  the  use  of  molded  wire  cages  (Figs.  78  and  79). 

G.  W.  Davis  suggests  the  use  of  wire  shapes  for  the  different  parts  of 
the  body,  having  in  the  upper  part  a  small  flat  tank,  and  going  from 
this  a  flexible  metal  tube  which  provides  a  constant  drip  of  salt  solution 
to  prevent  the  drying  out  of  the  grafts.  I  have  not  used  this  method 
but  see  no  reason  why  it  should  not  be  good.  Exposure  to  light  and 
air  are  without  doubt  beneficial,  but  too  early  drying  is  harmful  to 
freshly  placed  grafts. 

A  METHOD  OF  SPLINTING  SKIN  GRAFTS 

There  are  many  partial  takes  and  utter  failures  for  the  reason  that 
the  grafts  are  not  properly  splinted  after  they  have  been  applied,  and 
in  consequence  slip  down  with  the  dressings,  or  are  floated  off  by  blood 
or  serum  collecting  beneath  them.  In  order  to  overcome  this  difficulty 
it  is  necessary  to  reinforce  the  grafts  with  some  material  which  has 
enough  body  to  act  as  a  splint,  and  at  the  same  time  is  not  too  rigid  to 
shape  itself  readily  to  any  desired  situation.  It  is  important  that  it 
should  not  adhere  to  the  grafts  and  granulations,  or  cause  too  much 
pressure,  and  should  also  allow  of  the  free  escape  of  any  secretions  into 
the  dressings. 

After  experimenting  with  various  materials,  I  tried  a  coarse- 
meshed  net,  such  as  is  used  for  curtains.  It  is  made  of  loosely  woven 
flat  bars  of  cotton  thread,  surrounding  openings  about  i.  cm.  {%  inch) 


THE  TRANSPLANTATION  OF  SKIN 


73 


in  diameter.     It  is  necessary  to  have  the  openings  approximately  this 
size,  as  smaller  ones  become  clogged  (Fig.  80). 

In  order  to  increase  the  body  of  the  fabric,  after  washing  out  the 
sizing  and  drying,  the  material  should  be  saturated  with  a  solution  of 
pure  gutta-percha,  from  15  to  30  parts  (depending  on  the  stiffness  of 
the  material  required)  and  chloroform  150  parts.  After  the  chloro- 
form has  evaporated  and  the  material  is  dry  we  have  a  very  satisfactory 
splinting  material.  When  properly  prepared,  the  mesh  should  be  of  a 
light  greyish-brown  color  throughout. 


Fig.   80. — The    actual    size    of    the    openings   in   the   rubber  impregnated  mesh,  used  for 

splinting  grafts. 

Sterilization  Before  Application. — Cut  the  fabric  into  pieces 
as  large  as  may  be  desired  and  separate  them  with  one  or  two  thicknesses 
of  gauze.  Place  in  a  sterile  jar  and  fill  with  i  to  1000  bichloride  of 
mercury  solution.  Change  this  solution  three  times  at  twelve-hour 
intervals,  and  finally  allow  the  mesh  to  remain  permanently  in  the 
I  to  1000  bichloride  solution.  It  can  be  kept  for  a  considerable  time 
in  this  way  (I  have  used  it  after  keeping  it  twelve  months  in  the  bichlo- 
ride solution),  although  it  is  more  desirable  to  make  small  quantities 
as  required. 

Another  method  of  preparation  is  to  cover  the  rubberized  mesh 
with  60  per  cent  alcohol  for  24  hours,  and  then  pour  off.  Then  cover 
again  with  60  per  cent  alcohol  and  after  12  hours  the  mesh  is  ready  for 
use.  The  alcohol  is  prepared  from  a  stock  solution  of  bichloride  of 
mercury  i  part,  95  per  cent  alcohol  2000  parts. 


74 


PLASTIC  SURGERY 


The  dry  permeated  material  will  keep  indefinitely.  No  hot  solu- 
tions must  come  in  contact  with  the  mesh  during  the  sterilization  or 
application. 

Technic  — After  the  grafts  are  in  place  the  mesh  is  taken  out  of  the 
solution  and  thoroughly  rinsed  with  salt  solution,  then  dried  with  a 
sterile  towel.  A  piece  is  cut  large  enough  to  allow  for  a  margin  around 
the  grafted  area  of  from  5.  to  lo.  cm.  (2  to  4  inches).  Then  the  material 
is  applied  and  pressed  snugly  down  on  the  grafted  area  and  surrounding 
skin  or  granulations.  Should  the  conformation  of  the  part  or  wound 
not  permit  the  mesh  to  be  evenly  applied,  a  few  cuts  with  scissors,  will 


Fig.    81. — Extensive  third-degree  burn  of  the  chest  and  abdominal  wall. 

1.  The  burn  several  weeks  after  admission. 

2.  The  lower  portion  healed  and  the  upper  portion  covered  with  rubber  impregnated 
mesh  which  secures  the  grafts.  This  wound  was  completely  healed  by  means  of  auto  and 
iso  grafts,  and  no  contracture  has  followed. 

permit  infolding  and  accurate  fitting,  which  is  necessary  in  order  that 
the  splinting  may  be  successful.  The  overlapping  edges  may  be  secured 
to  the  skin  by  strips  of  adhesive  plaster  when  necessary.  After  the  net 
is  in  position  the  dressing  selected  is  applied,  and  the  whole  is  secured 
with  a  bandage. 

Where  the  overlapping  material  rests  on  granulation  tissue,  it  will 
be  found  that  it  can  be  lifted  up  at  any  time  without  causing  pain  or 
bleeding,  as  the  granulations  do  not  adhere  to  or  grow  into  the  bars 
of  the  impregnated  material. 

With  this  mesh  in  place  the  grafts  can  be  observed  from  time  to  time 
with  little  or  no  danger  of  displacing  them.     Should  any  blisters  form, 


THE  TRANSPLANTATION  OF  SKIN  75 

and  serum  or  l)loo(l  collect  beneath  the  grafts,  it  can  be  removed  at  once 
without  disturbing  the  mesh.  The  first  dressing  is  usually  made  in 
from  32  to  72  hours  after  operation,  and  the  wound  may  be  irrigated 
with  salt  solution,  or  secretions  may  be  wiped  away.  The  mesh  is 
left  in  place  for  from  4  to  10  days,  and  then  can  be  removed  without 
difficulty  (Fig.  81). 

Any  type  of  dressing  may  be  used  over  this  material  (silver  foil, 
wet  or  dry  gauze,  etc.)  and  I  have  found  it  particularly  desirable  in  those 
cases  in  which  the  grafted  area  is  exposed  to  the  air. 

I  have  used  this  open-meshed  material  over  Ollier-Thiersch  and 
whole-thickness  grafts  on  nearly  every  part  of  the  body,  and  have 
found  its  use  distinctly  advantageous.  The  openings  in  this  mesh  are 
too  large  for  application  over  small  deep  grafts. 

Perry  described  a  method  of  impregnating  silk  netting  with  par- 
affin for  the  retention  of  skin  grafts;  he  reports  very  satisfactory  results, 
and  believes  his  method  to  be  much  simpler  than  the  one  mentioned 
above. 

Tennant  prepares  a  loose-meshed  bandage  by  soaking  it  for  12  hours 
in  rubber-tire  cement,  which  is  diluted  with  gasoline,  and  after  it  has 
dried  it  can  be  sterilized  by  boiling.  The  material  is  used  as  a  bandage 
to  hold  the  grafts  in  place.  The  disadvantage  of  the  material  is,  that 
the  mesh  is  too  small. 

Untoward  Possibilities. — The  wound  from  which  the  graft  is 
cut  usually  heals  promptly  and  leaves  a  slight  scar.  In  several  in- 
stances, however,  in  the  series  of  cases  at  the  Johns  Hopkins  Hospital 
phlebitis  followed  the  cutting  of  Ollier-Thiersch  grafts  from  the  left 
thigh,  whereas  no  such  condition  was  observed  after  they  had  been 
cut  from  the  right  thigh.  Occasionally  keloid  may  develop  in  the  scar 
from  which  the  graft  is  cut,  and  I  have  seen  cases  in  which  the  entire 
anterior  portion  of  the  thigh  was  covered  with  a  thick  keloid  growth 
following  the  cutting  of  an  extensive  Ollier-Thiersch  graft.  These 
grafts  had  been  skilfully  cut  and  were  very  thin,  and  the  healing  has 
been  without  infection  (Fig.  82). 

Contracture  may  occur  under  a  successful  Ollier-Thiersch  graft, 
nor  is  there  any  way  of  anticipating  or  preventing  it,  the  cicatricial 
tissue  forming  under  and  between  the  grafts.  McBurney  thought  it 
was  due  to  the  too  early  abandonment  of  wet  dressings,  but  no  more  of 
these  cases  occur  when  only  dry  dressings  are  employed  than  when  wet 
dressings  are  used  throughout. 


76 


PLASTIC  SURGERY 


Results. — Sometimes  Ollier-Thiersch  grafts  may  be  closely  adherent 
to  the  underlying  tissues,  although,  subsequently  they  may  become 
movable,  and  this  is  in  marked  contrast  to  the  whole-thickness  grafts, 
which  are  much  more  movable  from  the  beginning.  In  positions  where 
the  grafted  area  is  exposed  to  constant  trauma  Ollier-Thiersch  grafts 
are  contraindicated. 


Fig.   82. — Keloid  development  on  the  -.high  in  a  portion  of  a  scar  from  which  an  Ollier- 
Thiersch  graft  has  been  cut. 
A  large  keloid  can  be  seen  and  in  addition  there  are  several  smaller  growths  in  other 
portions  of  the  scar. 


SPECIAL  METHODS  OF  OBTAINING  OLLIER-THIERSCH 

GRAFTS 

IMany  special  knives  and  instruments  have  been  devised  for  cutting 
grafts,  among  which  Mixter's  rectangular  fenestrated  curved  plate 
may  be  mentioned.  On  the  under  surface  of  this  plate  is  a  row  of  sharp 
needle  points  which  serve  to  keep  it  in  place.  The  outer  edge  of  the 
plate  is  quite  thick  and  gradually  tapers  off  until  the  window  is  reached 
where  it  is  very  thin.  The  skin  of  the  thigh  is  stretched  and  the  plate 
is  applied.  Then  the  roller  is  pressed  firmly  down  upon  it,  thus  flatten- 
ing the  skin  between  the  thin  edges  of  the  plate,  and  the  graft  is  cut 


THE  TRAXSPLAXTATIOX  OF  SKIN  77 

with  a  saw-shaped  knife,  which  follows  the  roller  at  a  suitable  distance. 
With  this  instrument  smooth-edged,  narrow  grafts  of  uniform  thick- 
ness can  be  cut. 

Hoffmann  uses  a  knife  with  a  safety  guard  and  by  means  of  screws 
can  regulate  exactly  the  thickness  of  the  graft.  I  have  found  this 
knife  much  more  useful  without  the  guard  (Figs.  83-87). 


Fig.  83. — Thiersch's  knife  for  cutting  thin  grafts.  The  single  edged  blade  is  ground 
flat  on  both  sides.  The  blade  which  is  8.  cm.  (3^^  inches)  long  and  1.75  cm.  (Jlo  inch) 
wide,  is  placed  at  an  angle  to  the  handle,  which  is  advantageous  in  cutting. 

DooUttle  has  had  success  with  an  ordinary  safety  razor,  and  says 
that  no  skill  is  required,  and  good  grafts  of  uniform  thickness  can  be 
cut  with  this  simple  instrument. 

Lanz  cuts  a  long  Ollier-Thiersch  graft  and  divides  it,  then  stamps 
each  piece  with  a  die  which  cuts  a  row  of  transverse  incisions  down  the 


Fig.  84. — Kortuem's  knife  for  cutting  Ollier-Thiersch  grafts.  The  blade  is  double 
edged  and  very  thin.  It  is  16.  cm.  {6^5  inches)  long  and  1.75  cm.  (J-fo  inch)  wide.  This 
is  a  light  and  satisfactory  knife. 

center  of  the  graft,  and  a  parallel  row  of  incisions  on  each  side  at  the 
same  time  extending  from  the  edge  about  a  third  of  the  way  across 
between  the  central  incisions.  Then,  by  taking  hold  of  the  edges  he  is 
able  to  extend  the  graft  two  or  three  times  its  former  length.  He 
applies  one  of  these  opened  grafts  to  the  defect  to  be  covered;  the 


Fig.  85. — The  Catlin  amputating  knife,  which  is  used  at  the  Johns  Hopkins  Hospital 
for  cutting  Ollier-Thiersch  grafts.  It  is  double  edged,  and  the  size  most  commonly  used 
has  a  blade  17.  cm.  (6^^  inches)  long,  and  1.5  cm.  (^5  inch)  wide. 

Other  pieces  he  places  on  the  wound  left  by  the  cutting.  Both  w^ounds 
should  heal  rapidly  and  simultaneously.  He  holds  that  it  is  always 
advantageous  to  replace  any  excess  skin  on  the  wound  from  which  it 
has  been  cut,  but  ordinarily  such  a  wound  heals  so  promptly  that  this 
feature  of  Lanz's  technic  is  unnecessary.  The  small  open  spaces  in 
the  graft  allow  the  escape  of  secretions  and  soon  heal. 


78 


PLASTIC  SURGERY 


Parallel  incisions,  only  partly  through  the  skin,  to  form  the  lateral 
boundaries  of  the  grafts,  may  be  made  2.5  or  5.  cm.  (i  to  2  inches)  apart. 
Fischer  made  the  interesting  observation  that  grafts  obtained  from  and 
transplanted  upon  parts  which  have  been  previously  rendered  anemic 
by  the  use  of  a  rubber  bandage,  are  most  successful.     This  sugges- 


FiG.  86. — Rehn's  knife  for  cutting  Ollier-Thiersch  grafts.  This  is  a  very  heavy  well- 
balanced  knife.  The  under  surface  is  ground  flat,  and  the  back  of  the  blade  nearest  the 
handle  is  roughened  to  prevent  the  finger  from  slipping.  The  blade  is  12.  cm.  (4^-5  inches) 
long,  and  2.75  cm.  (i3'iO  inches)  wide. 

tion  however,  has  not  been  generally  adopted,  as  this  precaution  is 
unnecessary. 

In  cutting  grafts  it  must  be  remembered  that  elastic  shrinkage  takes 
place  at  once,  and  cicatricial  shrinkage  later. 

Thin  Ollier-Thiersch  grafts  of  uniform  thickness  take  better  than 
those  of  varying  thickness.     Large  grafts  cannot  be  cut  from  a  fat  or 


Fig.   87. — Hoffman's  knife   with  guard,   for  cutting  Ollier-Thiersch  grafts,      i.  Knife 
with  guard  in  place.      2.   Knife  and  guard  separated.      The  guard  is  secured  by  two  screws 

(a)  which  are  on  the  knife  itself.      The  thickness  of  the  graft  is  regulated  by  the  screws - 

(b)  which  are  on  the  guard. 

flabby  thigh.     It  is  difficult  to  cut  satisfactory  Ollier-Thiersch  grafts 
from  young  children  on  account  of  the  thinness  of  the  skin. 

The  Perforation  of  Grafts. — Vogel,  after  Olher-Thiersch  grafts 
are  in  place,  uses  curved  scissors  and  cuts  in  the  graft  two  small  windows, 
each  about  0.3  cm.  (3-^  inch)  square,  in  each  square  centimeter  of  sur- 
face.    He  uses  a  wet  salt  solution  dressing  for  four  or  five  days,  then 


THE  TRANSPLANTATION  OF  SKIN 


79 


dresses  with  an  ointment.  The  grafts  heal  smoothly  into  place  and 
are  never  lifted  up  by  blood  or  serum  collecting  beneath  them.  The 
little  windows  soon  heal  over,  but  before  this  takes  place,  they  allow 
free  escape  of  secretions  into  the  moist  dressings,  which  prevents 
drying. 

Forsterling,  instead  of  making  windows,  cuts  little  flaps  in  the  graft 
to  allow  drainage  as  long  as  necessary  and  does  not  leave  open  spaces 
to  be  covered  over. 


Fic.    ^,s. — Complete      uikc      I'i   ( Jllier-Thiersch  grafts  on   a   ^..-  .ng  a 

radical  operation  for  carcinoma  of  the  breast.      Photograph  taken  two  and  one-half  weeks 
after  grafting. 

These  methods,  especially  those  of  Vogel  and  Forsterling,  which 
are  very  simple,  have  much  to  recommend  them.  In  fact  the  recogni- 
tion of  the  necessity  of  allowing  the  immediate  escape  of  secretions 
which  collect  under  the  grafts  is  one  of  the  most  important  advances  in 
the  technic  of  Ollier-Thiersch  skin  grafting.  Experience  has  taught 
me  that  V-shaped  openings  should  be  made  here  and  there  in  any  graft 
wider  than  2.  cm.  (j^  inch). 

Methods  of  Making  the  Skin  Tense. — McBurney  introduced 
broad  sharp  retractors  to  hold  the  skin  flat  and  tense  while  the  graft  was 
being  cut  between  them;  but  two  pieces  of  splint  board,  as  previously 


8o  PLASTIC  SURGERY 

described,  will  hold  the  skin  in  a  very  satisfactory  manner.  Some  opera- 
tors use  the  hands  of  an  assistant  placed  above  and  below  for  stretching 
the  skin,  and  cut  between  them. 

Necessity  of  Contact. — Absolute  contact  is  necessary  and  this 
is  usually  obtained  by  pressing  the  graft  firmly  into  its  bed  with  gauze. 
Wight  suggests  sealing  the  graft  to  its  base  with  the  high-frequency 
current,  but  this  is  unnecessary. 

Ballance,  in  grafting  the  cavity  left  by  a  radical  operation  for  chronic 
middle-ear  disease,  in  order  to  obtain  absolute  contact  uses  suction 
through  a  very  fine  pipette,  which  extracts  the  air.  This  method 
might  be  used  to  advantage  in  causing  the  desired  contact  in  other 
larger  deep  cavities  requiring  a  skin  graft. 

Buried  Grafting. — Moszkowicz,  in  1916,  and  Esser,  inigiy,  de- 
scribed the  application  of  Ollier-Thiersch  grafts  stretched  on  molds 
buried  in  pockets  burrowed  in  the  tissues.  The  technic  of  Esser's 
"epidermic  inlay"  method  in  brief  is  as  follows  (in  referring  to  this 
method  hereafter  I  will  use  the  term  "buried  grafting").  He  makes 
the  pocket  which  he  desires  to  line  and  then  takes  an  impression  of  it 
with  sterilized  dental  impression  material.  When  this  hardens  it  is  re- 
moved and  over  it  is  stretched  a  very  thin  Ollier-Thiersch  graft,  raw 
surface  outward.  This  mold  covered  with  the  graft  is  then  inserted 
into  the  pocket,  and  the  skin  is  sutured  over  it.  Thus  the  graft  is  im- 
mobilized and  is  applied  to  the  raw  surface  evenly  and  under  slight 
pressure.  After  14  to  21  days  the  wound  is  opened,  the  mold  is  re- 
moved, and  the  plastic  operation  previously  planned  is  performed. 

This  method  is  a  valuable  one,  and  can  be  used  in  many  situations 
and  in  a  number  of  combinations.  It  is  especially  useful  in  lining  cheek 
or  lip  defects. 

Method  of  Securing  Two  Grafts  from  the  Same  Area. — Masson 
reports  a  method  of  securing  two  grafts  from  the  same  area  of  skin. 
He  cuts  an  Ollier-Thiersch  graft  with  a  razor,  and  then  immediately 
cuts  another  thin  graft  in  one  piece,  or  a  number  of  small  deep  grafts, 
from  the  raw  surface.  In  order  to  reduce  the  size  of  the  wound  he 
excises  an  elongated  ellipse  of  the  tissue  left  after  removal  of  the  two  . 
grafts,  and  approximates  the  edges  with  sutures.  This  method  of 
closure  would  be  of  little  use  except  in  cases  in  which  narrow  Ollier- 
Thiersch  grafts  had  been  cut. 

I  have  frequently  cut  grafts  of  all  types  from  areas  from  which 
Ollier-Thiersch  grafts  had  previously  been  taken,  but  only  after  this 
area  had  healed. 


THE  TRANSPLANTATION  OF  SKIN  8l 

OTHER  METHODS  OF  OBTAINING  THIN  GRAFTS 

Kellock  uses  a  combination  graft  cut  in  one  piece.  He  marks  out 
the  square  whole-thickness  portion,  then  with  a  sharp  razor  cuts 
OUier-Thiersch  grafts  to  the  margins  and  turns  them  back;  he  then 
cuts  the  deep  graft.  This  method  is  unnecessarily  complicated  and 
leaves  a  defect  to  be  filled. 

von  Mangoldt's  method  is  to  scrape  the  skin  with  a  razor  after 
it  has  been  carefully  cleaned.  He  discards  the  first  scraping  from  the 
surface,  but  when  fine  punctate  bleeding  from  the  tops  of  the  papillae 
is  seen,  the  layer  with  most  vitality  has  been  reached.  He  then  scrapes 
thoroughly  and  transfers  the  mixture  of  blood  and  epithehal  cells  to 
the  fresh  wound  and  spreads  its  out  evenly.  This  method  is  simple 
and  convenient,  and  requires  much  less  material  to  cover  extensive 
surfaces  than  do  other  technics. 

Noesske,  in  his  paper  on  von  Mangoldt's  method  of  grafting,  claims 
that  it  has  special  advantages  in  lining  cavities  in  long  bones  after 
operations  for  osteomyelitis.  The  cosmetic  results  are  better  than  with 
the  Ollier-Thiersch  method,  but  the  wound  requires  a  longer  time  for 
healing.  The  procedure  is  best  adapted  to  surfaces  not  exposed  to 
friction.     I  have  had  some  success  in  selected  cases  with  this  method. 

Lusk's  Method. — ^Lusk,  in  1895,  tried  dried  shreds  of  epidermis  over 
extensive  burns  because  no  other  skin  was  available.  He  secured 
such  good  results  that  he  began  to  experiment. 

The  epidermis  was  obtained  by  vesication  with  a  cantharides 
plaster,  or  from  accidental  burns  and  scalds.  The  fresh  cuticle,  after 
being  cut  off,  was  spread  on  gauze  pads  or  glass  slides,  and  sterilized 
as  any  other  surgical  dressing.  It  was  then  thoroughly  dried  and 
kept  until  needed.  It  should  be  applied  dry  in  small  pieces  upon 
healthy  granulating  surfaces,  not  more  than  i.  cm.  (%  inch)  apart. 
He  used  gauze  saturated  in  balsam  of  Peru  one  part,  with  castor  oil 
eight  parts ;  this  dressing  was  not  changed  for  from  ten  days  to  two  weeks. 

Hodgin  successfully  transplanted  dry  epithelial  scrapings,  which 
were  sown  on  the  wound.  Kibbler  also  was  successful  with  thin 
sections  of  thickened  skin  from  the  palms  of  the  hands  and  soles  of  the 
feet.  I  have  had  very  indift'erent  success  with  the  methods  of  Lusk, 
Hodgin,  and  Kibbler. 

Thiersch,  in  1874,  cut  small  pin-point  grafts  from  the  growing 
epithelial  edge  surrounding  a  wound,  and  transplanted  them  upon  the 
wound  successfully.     M.   S.   Souchon  again  called  attention  to  this 


82  PLASTIC  SURGERY 

method  in  1909.  I  have  employed  it  successfully  on  several  occasions, 
and  also  have  shifted  out  on  the  wound  short  pedunculated  flaps  of 
this  same  pelhcle  (Fig.  89) . 

This  method  can  be  used  on  those  patients  who  object  to  the  removal 
of  skin  from  other  situations,  and  the  procedure  can  be  carried  out  with 
little  or  no  pain. 

WHOLE-THICKNESS  SKIN  GRAFTS  (WOLFE-KRAUSE) 

Krause  says  that  the  three  things  necessary  for  the  successful  trans- 
plantation of  whole-thickness  grafts  are  total  asepsis,  a  perfectly  dry 
technic,  and  suitable  preparation  of  the  area  to  be  grafted. 


Fig.  89. — Diagrammatic  drawing  showing  the  methods  of  utiUzing  the  pellicle  of  new 
skin  on  the  margin  of  a  granulating  wound  in  order  to  hasten  healing. 

The  dotted  portion  represents  normal  skin.  The  clear  area  between  the  deep  black 
lines  indicates  the  pellicle  of  new  skin.      The  shaded  area  is  the  granulating  surface. 

A.  The  outline  of  a  graft  which  may  be  transplanted  to  any  portion  of  the  granulating 
surface.  B  and  C  show  pedunculated  flaps  of  the  pellicle  shifted  out  on  the  surface  of  the 
wound.     B'  and  C  show  the  outlines  of  incisions  before  the  flaps  are  shifted. 

Preparation  of  the  Area  to  Receive  the  Grafts.— It  is  of  the  utmost 
importance  that  the  raw  surface  on  which  the  graft  is  placed  be  per- 
fectly dry.  It  is  often  difficult  to  check  the  oozing  and,  when  the- 
bleeding  cannot  be  stopped,  it  is  advisable  to  wait  for  a  day  or  two 
before  applying  the  graft.  If  the  graft  is  placed  on  an  oozing  wound  the 
chances  are  that  a  blood-clot  will  form  beneath  it,  which  will  often 
seriously  interfere  with  the  new  blood  supply.  If  the  graft  is  placed 
on  a  dry  surface,  it  has  a  tendency  to  prevent  further  oozing,  but  if  any 
bleeding  should  subsequently  begin  it  is  usually  localized  in  a  compara- 


TIIK  TRANSPLANTATION  OF  SKIN 


83 


tively  small  area  so  that  it  can  escape  through  the  perforations  in  the 
graft  or  between  the  stitches. 

Whole-thickness  grafts  may  also  be  successfully  placed  on  undis- 
turbed, healthy  granulations  which  are  level  with  the  skin  edges.  The 
grafts  should  be  placed  close  to  the  growing  edge  and  to  each  other  if 
more  than  one  is  used.  Whole-thickness  grafts  placed  on  dry  granula- 
tions will  adhere  to  them  closely,  and  no  sutures  may  be  necessary. 
Grafts  placed  on  granulations  at  first  project  above  the  surrounding 
skin,  but  later  assume  the  proper  level. 


Fig.  90. — The  outline  of  the  incisions  made  for  removing  a  whole-thickness  skin 
graft  from  the  leg.  Note  the  measurements  and  compare  them  with  those  of  the  next 
figure. 

Technic. — Mark  out  lightly  with  a  scalpel  on  the  skin  an  elongated 
ellipse,  bearing  in  mind  that  the  edges  of  the  wound  caused  by  removal 
of  the  graft  should  be  approximated  with  only  slight  tension.  Remove 
the  skin  with  the  underlying  fat  down  to  the  fascia  or  aponeurosis  cover- 
ing the  muscle.  As  soon  as  the  scalpel  has  penetrated  the  subcutaneous 
fat  the  skin  immediately  shrinks  to  about  two-thirds  of  its  original 
size  transversely  and  a  little  less  in  its  length,  so  that  this  shrinkage  must 
be  planned  for  (Figs.  90-92). 


84 


PLASTIC  SURGERY 


Fig.  91. — The  same  area,  viith  the  incision  carried  down  to  the  deep  fascia,  without  the 
graft  being  separated  from  its  bed.  A  comparison  of  the  measurements  with  those  of  the 
previous  figure  show  the  amount  of  retraction  of  the  skin  edges  and  contraction  of  the  graft. 
This  contraction  varies  slightly  according  to  the  location  from  which  the  graft  is    cut. 


Fig.  92. — Method  of  trimming  of?  the  subcutaneous  fat  from  a  whole-thickness  graft. 
The  graft  rests  with  the  skin  surface  on  the  fingers.  Beginning  at  one  end,  with  curved 
scissors,  the  fat  is  cut  as  close  as  possible  to  the  skin  and  is  rolled  away  from  the  scissors 
as  it  is  cut  ofT  in  one  piece.      The  greater  part  of  the  fat  may  be  removed  in  this  way. 


THE  TRANSPLANTATION  OF  SKIN 


85 


Wrap  the  graft  in  dry  gauze  until  the  wound  from  which  it  has  been 
taken  is  sutured  and  dressed.  Then  trim  off  all  the  fat  from  the  graft 
with  curved  scissors.  Perforate  it  in  several  places  with  a  saddler's 
punch  to  allow  the  escape  of  any  blood  or  secretions  which  may  collect 
(Figs.  93-94).  Fit  the  graft  into  the  defect,  either  in  one  piece  or  in 
several  pieces,  depending  on  the  shape  of  the  wound.  If  one  piece  can 
be  used  it  is  advisable  to  secure  it  without  tension  with  four  cardinal 


Fig.  93.  Fig.  94. 

Fig.  93. — Adjustable  leather  punch  with  which  openings  0.2,  0.3,  0.4  and  0.5  cm. 
(J-f  2  to  yj,  inch)  in  diameter  may  be  made. 

This  is  the  neatest  and  most  satisfactory  method  of  perforating  whole-thickness  grafts, 
and  should  always  be  used  if  the  instrument  is  available. 

Fig.   94. — Showing  methods  of  perforating  whole-thickness  grafts. 

The  upper  graft  has  been  perforated  with  a  leather  punch;  the  middle  and  lower  grafts 
have  been  button-holed  with  a  scalpel. 


sutures,  preferably  of  horsehair.  In  some  instances  a  continuous  horse- 
hair suture  is  used  to  fill  in  between  the  cardinal  sutures,  and  in  others 
a  few  interrupted  sutures.  The  cardinal  sutures  should  be  through  the 
full  thickness  of  the  graft,  but  the  sutures  between  should  be  placed 
superficially  and  should  be  as  close  as  possible  to  the  edges  of  the  graft 
and  surrounding  skin.  Occasionally  no  sutures  at  all  are  used,  as  the 
graft  adheres  closely  to  the  dry  w^ound,  but  where  no  sutures  are  used,  it 
is  advisable  to  secure  it  by  means  of  rubberized  mesh.  A  sHght,  even 
pressure  should  be  exerted  on  the  graft  to  hold  it  firmly  against  its  base, 


86  PLASTIC  SURGERY 

but  too  much  should  be  avoided,  as  it  interferes  with  the  vitality  of  the 
graft. 

The  graft  should  be  handled  as  little  as  possible,  and  the  necessary 
manipulations  should  be  most  gentle.  All  of  these  points  seem  trivial, 
but  on  them  depend  the  success  or  failure  of  this  type  of  graft.  An 
Ollier-Thiersch  graft  may  be  handled  with  much  less  consideration, 
without  causing  an  unsuccessful  transplantation. 

It  is  essential  that  the  wound  from  which  the  graft  is  taken  be  closed 
at  once  and  not  left  open,  as  would  necessarily  follow  if  an  irregularly 
shaped  piece  of  skin  of  any  considerable  size  was  removed.  It  is 
advisable  to  have  the  size  and  shape  of  the  defect  in  mind  when  cutting 
the  graft,  but  it  will  be  found  that  a  piece  of  whole-thickness  skin  after 
removal  of  the  fat  is  very  pliable  and  can  be  easily  fitted  into  irregular 
defects.  It  is  better  to  have  the  graft  too  large  than  too  small,  and  if 
the  defect  is  irregular,  after  removal  the  graft  may  be  cut  into  the  desired 
shape,  or  divided  and  pieced  together.  It  is,  of  course,  desirable  to  fill 
a  defect  with  a  single  piece  of  skin,  so  that  there  will  be  fewer  resulting 
scars,  but  this  is  often  impossible. 

Dressings. — Silver  foil;  dry  gauze;  or  moist  salt  gauze  constantly 
kept  w^et,  or  allowed  to  dry,  are  all  excellent  dressings.  Another 
dressing  which  I  have  found  useful  is  a  flexible  parafhn  mixture  used  by 
Carrel  for  another  purpose.^ 

Any  of  the  new  paraffin  mixtures  (Ambrine,  Parisine,  Redentol, 
Stanolind  Wax,  etc.)  wiU  act  equally  well.  These  dressings  may  be 
used  with  success,  but  none  of  them  should  be  used  exclusively,  as  the 
dressing  should  be  chosen  with  regard  to  the  surroundings  of  the  wound 
grafted.  For  instance,  it  is  more  satisfactory  to  dress  a  graft  near  the 
eye  with  moist  salt  gauze  which  is  kept  wet  and  often  changed,  as  by 
this  means  the  secretions  from  the  eye  are  controlled,  and  there  is  less 
danger  of  infection. 

Except  in  young  children  in  whose  cases  plaster  casts  are  indicated, 
it  is  well  to  keep  the  grafted  area  under  constant  observation,  without 
disturbing  the  position  of  the  part,  which  should  be  kept  immobile 
until  the  blood  supply  is  assured  (Fig.  95).  The  grafted  area  should 
be  protected  from  injury  for  at  least  six  weeks. 

Comments. — The  skin  may  be  taken  from  almost  any  situation 
where  there  is  sufficient  laxity  of  tissue  to  admit  the  suturing  of  the  edges 
of  the  wound  from  which  the  graft  is  taken. 

^Paraffin   52°,    18.   gm.;   parafSn  40°,  6.  gm.;  beeswax  2.  gm.;  castor  oil  2.  c.c.     Mix. 
Sterilize  in  the  autoclave  and  apply  at  body  heat  with  a  camel's-hair  brush  over  the  grafts. 


THE  TRANSPLAXTATIOX  OF  SKIN 


87 


Grafts  may  be  cut  the  whole  length  of  the  thigh,  and  from  as  wide 
an  area  as  can  be  sutured.  By  using  a  boomerang-shaped  incision  a 
very  long  and  wide  area  of  skin  may  be  secured  from  the  abdominal  and 
chest  walls. 

Not  infrequently  we  shall  lind,  after  removing  a  whole-thickness 
graft,  that  large  veins  that  have  not  been  cut  are  exposed.  It  is  better 
to  excise  these  veins,  otherwise  they  often  cause  pain  and  discomfort 
later. 

A  graft  of  whole  thickness  may  be  placed  in  the  midst  of  scar  tissue, 
and  accomplish  its  purpose,  because  in  these  cases  the  graft  is  more 


Fig.   95. — Plaster  cast  on  a  child's  arm  after  grafting  the  hand. 
Xote  that  the  elbow  is  flexed  and  that  the  cast  extends  nearly  to  the  shoulder.      In  this 
way  immobility  is  assured,  and  it  is  impossible  for  the  patient  to  shake  off  the  cast. 


stable  and  flexible  than  the  tissue  which  surrounds  it.  and  the  scar 
becomes  more  resistant  as  the  tension  is  relieved. 

In  whole-thickness  grafts  it  is  important  to  choose  the  skin  to  be 
transplanted  with  some  regard  to  the  type  of  skin  which  will  surround 
it.  For  instance,  it  is  best  where  transplantation  to  a  hairless  part  of 
the  face  is  proposed,  to  select  the  inner  forepart  of  the  upper  arm,  as 
it  is  thin  and  practically  without  hair. 

As  the  success  of  the  graft  depends  on  the  blood  supply  of  its  new 
bed,  it  follows  that  it  should  not  be  placed  on  denuded  cartilage  (with- 


88 


PLASTIC  SURGERY 


out  perichondrium)  or  be  used  for  bridging  over  defects.  Pedunculated 
flaps  should  be  used  for  this  purpose.  However,  grafts  can  be  success- 
fully placed  on  healthy  tendons,  fascia,  muscle,  cortical  and  spongy 
bone,  periosteum,  and  on  the  dura  mater. 

The  Ollier-Thiersch  method  will,  of  course,  remain  the  method  of 
choice  on  account  of  its  simplicity  and  smaller  operative  action,  but  in 
such  exposed  localities  as  the  elbow,  palm  of  the  hand,  knee,  or  heel, 


Pig.  96. — Result  of  whole-thickness  grafting  for  the  relief  of  a  contracture  of  the  palm 
and  fingers  following  a  burn  from  electricity.  Photograph  taken  eighteen  months  after 
grafting. 


where  there  is  a  good  deal  of  pressure  and  friction,  these  thin  grafts 
will  not  stand  the  strain. 

It  is  advisable  to  use  large  whole-thickness  grafts,  as  the  healing 
and  adhesion  is  as  good  as  with  small  ones,  and  there  are  fewer  scars 
and,  therefore,  less  likehhood  of  future  contracture. 

Extraordinary  results  have  been  obtained  from  the  use  of  whole- 
thickness  grafts  in  most  unfavorable  cases,  and  this  type  of  graft  should 
be  more  generally  utilized. 


THE  TRANSPLANTATION  OF  SKIN  89 

It  is  of  course,  always  wise  to  graft  a  suitable  defect  in  the  skin 
immediately  after  an  operation,  but  should  a  granulating  wound  be 
presented  we  have  to  decide  whether  it  is  best  to  graft  on  the  untouched 
granulations,  or  whether  the  granulating  wound  should  be  made  a  fresh 
one  by  the  removal  of  the  granulations.  My  own  observations  have 
convinced  me  that  both  thin  and  whole-thickness  grafts  take  as  well  on 
an  undisturbed  granulating  area  as  on  a  fresh  wound,  provided  that 
the  granulations  are  clean  (free  from  infection). 

Massage  of  the  grafted  area  and  surrounding  skin  is  very  advan- 
tageous, as  it  softens  the  graft,  renders  it  more  movable,  and  also  causes 
it  to  assume  more  rapidly  the  appearance  of  the  neighboring  skin. 
This  should  not  be  started,  however,  for  several  weeks,  i.e.,  until  after 
the  graft  is  firmly  adherent  to  its  base. 

Whole-thickness  grafts  are  used  somewhat  rarely  and  many  surgeons 
have  never   used  them,  preferring  the  thin  grafts. 

Although  the  operative  procedure  in  securing  thick  grafts  is  un- 
doubtedly more  severe  than  for  thin  grafts,  and  the  after-care  is  some- 
times tedious,  on  the  other  hand,  the  healing  following  a  successful 
whole-thickness  graft  is  as  stable,  firm  and  pliable  as  the  original  skin. 
I  believe  that  the  ultimate  result  will  more  than  justify  the  time  con- 
sumed, as  well  as  the  discomfort  experienced  by  the  patient  (Fig.  96). 

Tunnel  Grafting. — MacLennan  describes  what  he  called  "tunnel 
grafting. "  He  removes  a  whole-thickness  graft  and  then  cuts  this 
graft  into  pointed  strips  about  0.75  cm.  (^{q  inch)  wide  and  from  2.5  to 
5.  cm.  (i  to  2  inches)  long.  After  tunneling  with  forceps  below  the 
fibrous  layer  underlying  the  ulcer,  he  draws  the  graft  into  the  tunnel. 
Each  graft  is  marked  with  a  loop  of  horsehair  passing  through  the 
tunnel.  After  four  or  five  days  the  graft  is  exposed  by  cutting  down 
to  it. 

I  can  see  nothing  to  be  gained  by  such  a  method,  as  the  operative 
procedure  is  almost  as  severe  as  it  would  be  for  the  complete  excision 
of  the  ulcer  and  its  base,  followed  by  grafting  by  one  of  the  usual 
methods.  At  one  time  Reverdin  grafts  were  buried  in  the  granulations, 
but   this   method   was   soon   abandoned   as   unnecessary  (Pollock). 

Transplantation  of  Hair-bearing  Skin. — In  a  case  of  contracture 
in  which  the  eyebrow  has  been  destroyed,  carefully  shaped  whole- 
thickness  grafts  of  hairy  skin  from  the  pubes,  with  a  thin  layer  of  sub- 
cutaneous tissue,  may  be  successfully  transplanted  and  will  relieve 
the  contracture,  and  at  the  same  time  form  an  eyebrow.  In  transplan- 
tation of  skin  from  the  pubes  the  direction  of  the  hair  growth  should  be 


90  PLASTIC  SURGERY 

kept  in  mind.  Hair  also  grows  on  grafts  taken  from  the  thigh,  scalp, 
or  from  any  other  hairy  region.  For  this  reason  it  is  important  to 
choose  carefully  the  region  from  which  the  graft  is  taken  with  regard 
to  the  area  into  which  it  is  to  be  placed. 

Early  Changes. — In  Ollier-Thiersch  grafts  the  upper  layers  macerate, 
leaving  the  deeper  ones  intact.  In  whole-thickness  grafts  there  may 
be  practically  no  maceration  of  the  superficial  layers;  in  some  instances 
only  the  corium  may  remain  viable.  Now  and  then  an  isolated  section 
of  a  graft  will  lose  its  vitaHty  through  all  its  layers,  and  a  patch  of  granu- 
lation tissue  will  appear.  This  area  should  be  treated  as  any  other 
granulating  wound. 

When  the  superficial  layers  are  macerated  and  come  away,  either 
as  a  whole  or  in  part,  and  the  epithelization  of  the  remaining  corium  is 
sluggish,  it  is  desirable  to  scatter  over  these  areas  epithelial  scrapings, 
or  small  superficial  grafts  including  as  far  as  possible  only  epithelium. 
These  grafts  take  readily  and  hasten  the  epithelization.  The  final  result 
is  excellent. 

Subsequent  Changes.- — The  result  desired  in  whole-thickness  graft- 
ing is  elasticity,  softness,  movability  and  normal  color.  Krause  says 
that  all  of  these  are  obtained  in  only  one-third  of  complete  takes, 
although  the  same  technic  may  be  employed  in  all.  My  experience 
leads  me  to  believe  that  this  percentage  is  too  small. 

In  some  instances  a  brown,  irregular  pigmentation  may  appear, 
but  this  is  no  more  frequent  than  in  areas  grafted  with  thin  grafts, 
and  need  not  be  particularly  considered  in  cases  of  contracture  where 
function  is  more  important  than  appearance.  The  graft  may  be 
cyanotic  for  some  time,  owing  to  enlarged  blood-vessels;  later  the 
surface  of  a  graft  may  become  irregularly  shriveled.  These  changes  in 
no  way  impair  the  efiicacy  of  the  graft,  but  must  be  borne  in  mind  from 
the  cosmetic  standpoint,  and  the  possibihties  of  these  complications 
should  be  explained  to  the  patient. 

HISTOLOGICAL  CHANGES 

The  histological  changes  in  the  healing  process  of  any  type  of  skin 
graft,  are,  in  general,  similar  to  those  which  take  place  in  the  healing 
of  an  ordinary  clean  wound.  There  is  an  exudation  of  fibrin  from  the 
surface  upon  which  the  graft  is  placed,  which  fixes  the  graft  firmly  in 
position.  This  fibrin  layer  is  infiltrated  with  leucocytes  and  fibro- 
blasts.    Vascular  sprouts  soon  begin  to  form  and  penetrate  the  deeper 


THE  TRANSPLANTATION  OF  SKIN  9 1 

layers  of  the  graft,  so  that  in  a  comparatively  short  time  the  graft  is 
supplied  with  blood.  These  new  vessels  have  been  demonstrated  by 
the  injection  method  in  epidermic  grafts  on  the  second  day.  and  in 
whole-thickness  grafts  on  the  third  day.  As  early  as  the  sixth  day  a 
whole-thickness  graft  on  a  fresh  wound  will  bleed  when  cut  (Krause).  I 
have  obtained  bleeding  in  84  hours  from  a  whole-thickness  graft  placed 
on  healthy  undisturbed  granulations.  The  graft  itself  begins  to  take 
an  active  part  in  the  healing  process  after  the  third  or  fourth  day, 
there  being  marked  proliferation  of  cells  into  the  underlying  exudate, 
and  an  outgrowth  of  new  epithelial  cells  from  the  edges;  from  the  ducts 
of  the  sweat  glands,  and  from  hair  follicles.  Enderlen  sa3-s  the  fibrous 
and  elastic  tissues  of  the  graft  degenerate  and  are  replaced  by  newly 
formed  tissue  which  probably  develops,  at  least  in  part,  from  the  pre- 
existing elements  in  the  graft  itself,  as  well  as  from  the  old  fibers  in  the 
neighboring  deeper  tissues.  In  about  two  weeks  the  underlying  granu- 
lation tissue  is  replaced  by  connective  tissue,  and  this  is  finally  the  true 
cicatrix.  The  papillary  structure  of  the  newly  formed  skin  following 
Ollier-Thiersch  grafting,  is  said  to  be  well  marked  in  from  three  to  four 
months,  although  I  have  seen  the  beginning  of  the  papillary  structure 
two  weeks  after  grafting.  A  thin  layer  of  adipose  tissue  develops 
under  whole-thickness  grafts  denuded  of  fat  in  two  to  three  weeks. 
This  is  most  important,  as  it  prevents  to  a  large  extent  future  con- 
tracture and  insures  movability.  The  scar  tissue  beneath  the  graft 
continues  to  grow  for  several  months.  The  newly  grafted  area  must 
not  be  exposed  too  soon  to  irritation  or  trauma.  It  is  difiicult  to  guard 
against  this  until  the  nerve  supply  is  reestablished,  as  for  the  first  few 
weeks  the  graft  is  without  sensation.  Within  four  or  five  weeks  sen- 
sation begins  to  be  restored  to  the  transplanted  skin,  which  regains 
tactile  sensibility  first,  then  pain,  and  last  temperature  sense.  The 
nerve  fibers  undoubtedly  grow  in  from  the  periphery,  and  not  from  the 
substratum,  this  being  shown  by  the  fact  that  the  border  sections 
always  regain  sensation  first.  If  the  graft  is  large  the  central  portion 
may,  in  some  cases,  remain  less  sensitive  for  a  long  time,  but  usually 
the  sensation  is  entirely  restored  in  the  course  of  a  few  months. 

A  depressed  area  successfully  grafted  with  any  type  of  graft,  will 
eventually  fill  out  and  assume  the  level  of  the  normal  skin. 

CHANGES  IX  PIGMENTATION 

In  all  types  of  grafts  pigmentation  may  occur.     In  small  deep  grafts 
a  brownish,  blotchy  pigmentation  may  develop  both  in  the  grafts  and 


92  PLASTIC  SURGERY 

in  the  scar  between  them.  Ollier-Thiersch  and  whole-thickness  grafts 
may  also  assume  a  blotchy-brownish  color  which  is  permanent.  There 
is  no  way  of  preventing  this  pigmentation  and  the  patient  should  be 
warned  of  such  possibility. 

The  changes  occurring  in  the  pigmentation  of  transplanted  skin  are 
interesting.  It  is  to  be  noted  that  in  negro  skin  the  pigment  lies  almost 
entirely  in  the  deeper  cells  of  the  stratum  ]Malphighii.  and  is  practically 
lacking  in  the  superficial  cells.  Reverdin  established  the  fact  that  a 
pigmented  thin  graft  from  a  negro  transplanted  upon  the  white  skin 
gradually  fades,  and  this  has  been  confirmed  by  many  observers,  and 
also  by  our  experience  at  the  Johns  Hopkins  Hospital. 

PoHock.  however,  mentions  a  case  in  which  a  superficial  graft  re- 
mained colored.  Maxwell  reports  a  case  in  which  he  transplanted  a 
small  superfi-cial  graft  from  his  own  skin  in  addition  to  some  black  grafts 
upon  a  defect  on  a  negro's  face,  and  states  that  the  white  graft  remained 
white.  Two  cases  are  reported  by  J.  H.  W.  Mayer  in  which  negro 
skin  was  grafted  on  white  patients,  and  in  both  instances  the  grafts 
remained  black.  He  does  not  mention  the  kind  of  graft  used.  T. 
Bryant  also  reports  a  case  in  which  several  small  black  grafts  after 
transplantation  to  a  white  man  spread  and  joined  each  other,  and  finally 
made  one  black  patch  which  remained  black. 

Karg  says  that  a  white  graft  placed  on  a  negro,  after  six  weeks 
became  dusky,  and  from  the  edges  black  stripes  extended  into  the  white 
skin  and  black  points  or  spots  appeared  in  other  places.  The  pigment 
gradually  increased  and  in  ten  weeks  the  color  was  as  black  as  that  of 
the  surrounding  skin,  although  the  contour  of  the  transplanted  piece 
was  still  distinct.  In  another  case  of  a  black  Ollier-Thiersch  graft  on 
white  skin,  he  found  after  two  weeks  that  the  edges  of  the  graft  were 
lighter,  the  central  portion  then  faded,  and  in  about  five  weeks  also 
became  a  pale  grey.  The  microscopic  examination  of  the  white  skin 
grafted  on  the  negro  showed  that  after  four  weeks  the  epidermis  in  the 
center  was  entirely  free  of  pigment.  Numerous  ramified  pigment 
cells  were  found  in  the  periphery,  on  the  boundary  line  between  the 
cutis  and  epidermis,  which  had  sent  fine  oft'shoots  between  the  cells  of 
the  epidermis.  Granular  pigment  was  found  here  and  there  in  the 
epidermic  cells,  especially  near  the  ramified  pigment  cells.  Pigment 
granules  were  also  found  in  the  upper  layers  of  the  cutis,  particularly 
in  the  neighborhood  of  the  vessels.  All  of  these  were  much  increased 
after  eight  weeks,  and  after  twelve  weeks  the  pigmientation  was  so 
intense  that  the  offshoots  of  the  pigment  cells  could  not  be  made  out. 


THE  TRANSPLANTATION  OF  SKIN 


93 


From  these  observations  Karg  concludes  that  the  pigment  is  brought 
to  the  colorless  epidermic  cells  by  cells  of  a  connective  tissue  nature 
derived  from  the  cutis,  and  that  they  represent  special  chromatophores. 

The  black  skin  grafted  on  the  white  was  within  six  weeks  entirely 
free  of  pigment,  except  single  pigment  granules  in  the  corneal  layer, 
and  larger  flakes  in  the  cutis.  Single  cells  containing  pigment  were  also 
found  deeper  down.  The  pigment,  therefore,  seems  to  be  taken  up  and 
removed  by  migratory  cells.  The  ramified  cells  with  offshoots  can  be 
seen  between  the  epidermic  cells,  but  contain  no  pigment.  It  is  inter- 
esting to  note  that  when  a  whole-thickness  black  graft  is  placed  on  a 
black  patient,  the  layers  containing  the  pigment  are  cast  off,  and  the 
graft  becomes  entirely  white  but  the  pigment  slowly  returns  in  the  course 
of  time. 

Leo  Loeb  experimented  by  transplanting  the  pigmented  skin 
of  a  guinea-pig  to  a  place  where  the  skin  was  unpigmented,  or  con- 
versely. He  says  that  following  the  transplantation  the  black  skin 
not  only  keeps  its  own  pigment,  but  after  a  variable  period  the  boun- 
daries of  the  transplanted  skin,  which  before  were  very  distinct,  become 
indistinct,  a  darker  line  appearing  at  the  margins,  and  gradually  the 
pigmented  area  spreads  in  the  white  skin.  A  similar  thing  happens 
under  certain  conditions  where  white  skin  is  transplanted  to  black,  the 
black  pigment  spreading  in  the  white  skin.  Loeb  thinks  that  the  living 
white  epithelium  is  replaced  by  the  transplanted  black  epithelium 
through  a  process  of  infiltration,  and  that  under  these  circumstances 
there  are  no  signs  of  phagocytosis,  by  which  the  black  cells  destroy 
the  white  ones,  and  further  that  the  chromatophores  originate  from  the 
epithelium  itself  and  at  no  time  are  migratory  from  deeper  tissues. 

Karg  and  Loeb  both  worked  along  similar  lines,  but  Karg  used 
Ollier-Thiersch  grafts  on  human  beings,  whereas  Loeb  experimented 
with  whole-thickness  grafts  on  guinea-pigs.  The  findings  of  Karg  are 
generally  accepted,  and  seem  the  most  reasonable. 

I  was  able  to  transplant  several  white  whole-thickness  grafts  upon 
negroes,  and  found  that  after  a  considerable  time  they  became  dusky, 
the  duskiness  starting  especially  on  the  portion  of  the  graft  nearest  the 
normal  skin.  On  those  grafts  which  were  placed  at  some  distance  from 
the  skin  edges,  pigmentation  occurred  a  good  deal  later,  as  it  was  appar- 
ently necessary  for  the  intervening  space  to  become  pigmented  before 
the  graft  took  on  its  pigment.  In  the  cases  in  which  negro  whole- 
thickness  grafts  have  been  placed  on  white  skin,  the  pigment  layer  is 
soon  cast  off,  and  as  yet  I  have  seen  no  return  of  the  pigment. 


94  PLASTIC  SURGERY 

In  considering  the  loss  of  pigment  in  a  black  graft  transplanted  to  a 
white  person,  and  the  acquisition  of  pigment  by  a  white  graft  placed  on  a 
colored  person,  we  must  bear  in  mind  the  fact  that  sometimes  both  auto 
and  iso  white  grafts  become  pigmented,  and,  moreover,  that  both  auto 
and  iso  black  grafts  at  first  lose  their  pigment,  although  the  pigment 
subsequently  returns  (Fig.  97). 


Fig.  97. — Returning  pigmentation  in  an  unpigmented  scar  on  the  leg  of  a  negro.  The 
pigment  can  be  seen  spreading  from  the  edges  and  also  appearing  in  isolated  patches 
entirely  separated  from  the  edges.  The  return  of  pigmentation  in  grafts  is  somewhat 
similar  to  this. 

Should  a  white  graft  placed  on  a  colored  person,  or  a  black  graft 
placed  on  a  white  person,  be  unsuccessful,  the  resulting  scars  always 
eventually  assume  the  color  of  the  host. 

BIBLIOGRAPHY 

Abbe.     "Med.  Record."     New  York,  Oct.  12,  1878,  313. 
Agnew,  D.  H.     "Med.  &  Surg.  Rep.,"  1874,  xxxi,  424. 

"Principles  and  Practice  of  Surgery,"  1878,  i,  124. 
Alglave,  p.     "Presse  med.,"     Paris,  July  23,  1817,  419. 

Ballance,  C.  a.     "Med.-Chir.  Trans."     London,  1900,  Ixxxiii,  125. 
Baratoux  and  Dubosquet-L.vborderie.     "Gaz.  d.  hop.,"  1886,  Nr.  145. 
"Progres  med.,"  1887. 


THE  TRANSPLANTATION  OF  SKIN  95 

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CHAPTER  V 
THE  TRANSPLANTATION  OF  OTHER  TISSUES 

The  remarks  on  transplantation  of  tissues  other  than  the  skin  will  be 
confined  to  their  relationship  to  plastic  surgery;  no  exhaustive  consider- 
ation of  the  subject  will  be  attempted. 

I  wish  to  especially  emphasize  again  the  importance  of  asepsis  and  of 
absolute  hemostasis  in  the  transplantation  of  all  tissues. 

The  Transplantation  of  Fascia 

Fascia  is  used  in  plastic  surgery  for  a  number  of  purposes.  It  is 
valuable  for  reinforcing  weakened  or  defective  tissues.  New  tendons 
may  be  constructed  of  it.  It  may  be  used  for  the  relief  of  ptosis  (of 
the  eyelidj,  and  for  raising  the  drooping  angle  of  the  mouth  following 
facial  paralysis.  It  may  also  be  used  either  alone  or  with  fatty  tissue  in 
the  mobilization  of  joints.  It  may  be  used  free  or  as  a  pedunculated 
flap.  If  free  fascia  is  placed  in  tissue  devoid  of  scar  tissue,  it  will 
survive  indefinitely  and  retain  its  own  characteristics  (D.  Lewis). 
If  scar  tissue  is  present,  the  fascia  becomes  infiltrated  with  it,  and 
although  it  usually  is  efficient  for  carrying  out  the  purpose  for  which  it 
was  transplanted,  its  microscopic  picture  will  have  changed.  Free 
fascia  flaps,  with  or  without  fatty  tissue,  have  been  used  successfully 
in  filling  bone  defects  in  the  skull. 

Tubes  of  fascia  are  useful  between  severed  nerve  stumps;  they  are 
valuable  in  guiding  the  formation  of  the  protoplasmic  bands  and  subse- 
quently the  axis  cylinders. 

-^  Transplantation  of  Bone 

Bone  and  cartilage  are  normally  the  supporting  framework  for  the 
soft  parts,  and  both  are  used  for  this  purpose  in  reconstructive  surgery. 
When  bone  is  chosen  for  the  supporting  substance,  it  is  advisable  to 
leave  the  periosteum  and,  if  possible,  the  endosteum  intact.  It 
must  be  borne  in  mind  that  free  grafts  of  bone,  either  with  or  without 
periosteum,    when    transplanted    into    soft    parts    will  eventually  be 


THE  TRANSPLANTATION  OF  OTHER  TISSUES  lOI 

absorbed.  I  have  found,  experimentally  and  clinically,  that  a  bone 
graft  in  contact  with  bone  at  one  end,  and  extending  into  the  soft  parts 
without  special  function,  will  become  thin  and  eventually  lose  its  power 
to  act  as  a  proper  support.  On  the  other  hand,  if  the  bone  transplant 
is  placed  in  contact  w^ith  living  bone  at  each  end,  it  will  become 
a  permanent  supporting  framework.  Whether  the  graft  lives  or  is 
replaced,  is  still  a  matter  of  dispute,  the  argument,  for  which  will  not 
be  considered  here. 

Bone  grafts  are  usually  obtained  from  the  crest  of  the  tibia  or  from 
the  ribs;  occasionally  from  the  scapula,  or  sternum.  If  the  tibia  is  used, 
the  bone  with  its  periosteum  is  removed  with  an  electricallv  driven  saw, 
or  a  very  thin  bladed  steel  chisel.  If  the  rib  is  used,  the  periosteum  on 
the  exposed  surface  may  be  removed  with  the  rib,  while  the  rest  of  the 
bone  is  shelled  out  subperiosteally.  The  bone  from  the  rib  is  porous; 
it  is  much  more  readily  shaped  than  bone  from  the  tibia,  and  is  easy 
to  secure.  Bone  grafts  in  a  bone  defect  need  not  be  as  large  in  diameter 
as  the  defect,  as  the  tendency  is  for  the  new  bone  to  increase  in  size  and 
strength  to  meet  the  strain  demanded  of  it.  Autobone  grafts  are 
preferable,  but  many  successful  cases  of  isobone  transplantation  are 
reported. 

Infection  does  not  always  destroy  a  bone  graft,  and  enough  may  be 
left  to  accomplish  the  purpose  for  which  it  has  been  transplanted.  Sec- 
tions of  bone  which  have  not  been  separated  from  soft  parts  are  some- 
times used  in  pedunculated  flaps.  This  subject  will  be  dealt  with  in 
another  section. 

Transplantation  of  Cartilage 

Cartilage  is  an  ideal  supporting  substance  for  transplantation,  when 
too  much  strain  will  not  be  placed  upon  it,  and  will  live  and  not  shrink 
when  transplanted  free  (either  with  or  without  its  perichondrium;  into 
soft  parts.  It  will  also  live  when  in  contact  with  bone  at  one  or  both 
ends,  although  the  union  between  bone  and  cartilage  will  not  be  rigid. 

Cartilage  is  flexible  and  thus  less  liable  to  subsequent  fracture;  it  can 
be  easily  cut  and  shaped  into  any  desired  form ;  it  is  not  more  difiicult  to 
obtain  than  bone,  and  a  large  supply  is  always  available.  Any  one  of 
these  advantages,  it  seems  to  me,  would  suggest  the  use  of  cartilage 
rather  than  of  bone  for  the  supporting  material  in  transplantation  for 
the  correction  of  saddle  nose,  the  filling  out  of  sunken  areas  on  the  face, 
and  also  for  the  framework  in  rhinoplastic  operations.  It  is  the  best 
material  to  use  in  compound  flaps  in  rhinoplastic  work. 


I02 


PLASTIC  SURGERY 


Rib  cartilage  is  the  usual  source  of  supply.  The  cartilage  may  be 
obtained  from  the  costal  margin  on  either  side.  All  things  being 
equal.  I  prefer  the  left  side  and  usually  the  eighth  rib,  which  can  be 


Fig.  98. — Schematic  drawing  of  the  cartilaginous  ribs  showing  the  skin  incisions  for 
obtaining  cartilage  grafts;  line  of  pleural  reflection;  the  position  of  the  internal  mammary 
artery.      rSuperior  epigastric  artery  below  the  ribs.j 

removed  with  safety.     After  removal  it  can  be  shaped,   either  free 
hand  or  according  to  a  pattern.     When  broader  pieces  are  necessary 


3  cm. 

Fig.  99. — Slicing  knife  devised  by  Villandre  to  remove  the  anterior  portion  of  cartilaginous 

ribs.      (Woodroffe.) 
With  this  instrument  portions  of  the  cartilage  may  be  removed  without  cutting  through 
the  full  thickness  of  the  rib.      By  its  use  the  danger  of  injuring  the  internal  mammary 
artery  can  be  avoided. 

the  fused  portions  of  the  cartilage  of  the  sixth  and  seventh  ribs  may  be 
used.     Care  must  be  taken  to  avoid  opening  the  pleura.     On  removing 


THE  TRANSPLANTATION  OF  OTHER  TISSUES  IO3 

the  desired  portion  of  the  fused  cartilage  closer  to  the  sternum  than  the 
eighth  rib,  one  must  try  to  avoid  cutting  the  internal  mammary  artery 
(Figs.  98  and  99). 

Certain  cases  require  cartilage  transplants  at  different  times  in 
the  course  of  extensive  reconstructive  work.  The  entire  amount  may 
be  removed  from  the  cartilaginous  ribs  at  the  time  of  the  first  operation 
in  which  cartilage  is  used.  Those  portions  which  are  to  be  employed 
subsequently  may  be  implanted  subcutaneously  in  any  convenient  situa- 
tion, and  be  used  when  needed.  This  procedure  saves  a  great  deal  of 
time,  often  avoids  the  necessity  of  a  general  anesthetic,  and  eliminates 
a  great  deal  of  pain. 

Cartilage  has  been  used  to  fill  in  defects  left  after  enucleation  of  the 
eye,  to  construct  new  supraorbital  ridges,  and  other  parts  of  the  orbit, 
to  repair  skull  defects,  to  replace  missing  phalangeal  bones,  and  for 
many  other  purposes.  It  is  by  far  the  most  useful  and  dependable 
of  the  supporting  substances. 

In  large  defects  the  cartilage  may  be  used  in  one,  or  in  several 
pieces.  In  has  been  used  to  fill  out  loss  of  substance  even  in  the  mandi- 
ble with  success.  The  cartilage  grafts  must  be  of  the  same  size  as  the 
defect  it  is  to  fill,  because,  unlike  bone,  it  remains  unchanged,  and  neither 
increases  in  size  nor  shrinks. 

Isocartilage  has  been  often  used  and  Morestin  reports  many  success- 
ful cases  in  his  work  on  wounded  soldiers. 

On  account  of  the  adequate  supply  it  is  advisable  to  use  auto- 
cartilage. 

I  have  seen  cases  in  which  infection  followed  the  insertion  of  a 
cartilage  graft,  and  the  cartilage  was  visible  through  a  sinus.  In  spite 
of  this,  following  the  free  use  of  tincture  of  iodin,  the  graft  retained  its 
vitality  and  eventually  accomplished  the  purpose  for  which  it  had  been 
transplanted. 

Transplantation  of  Fat 

Free  fat  grafts  are  used  in  plastic  surgery  principally  for  filling 
depressions;  for  restoring  mobility  in  adherent  scars  and  preventing 
subsequent  adhesions  and  contractures. 

Thin  or  thick  sheets,  or  masses  of  free  fat,  can  be  successfully  trans- 
planted. Some  surgeons  prefer  a  number  of  small  pieces;  others  make 
one  graft  the  size  of  which  is  limited  only  by  the  area  to  be  filled.  My 
experience  has  been  that  the  size  should  depend  to  a  large  extent  on  the 
■opening  through  which  the  fat  is  to  be  inserted,  as  sometimes  it  is 


I04 


PLASTIC  SURGERY 


expedient  to  make  a  small  opening  to  an  undercut  area  of  some  size. 
My  own  preference  is  for  the  large  single  sheet  or  mass.  It  is  always 
wise  when  using  fat  for  obliterating  depressions,  to  bear  in  mind  that 
shrinkage  invariably  follows  and  that  more  fat  must  be  transplanted 
than  seems  to  be  required. 

If  exposure  is  possible,  I  prefer  to  anchor  the  fat  in  position  with  a 
few  fine  catgut  sutures.  Fat  should  not  be  packed  too  tightly  into  its 
new  bed.  Asepsis  is  essential  for  success,  although  I  know  of  several 
cases  in  which  the  fat  has  resisted  infection  and  sufficient  has  survived 
to  accomplish  its  purpose.  The  bed  into  which  the  fat  is  placed  must  be 
perfectly  dry. 

Often  after  fat  transplantation  a  varying  amount  of  oily  fluid 
collects,  which  is  undoubtedly  due  to  the  breaking  down  of  some  of  the 
fat  cells.  This  fluid  may  give  the  impression  of  infection,  but  if  it  is 
evacuated  through  a  small  opening  in  the  suture  line,  under  strict  asep- 
tic precautions,  the  wound  (after  drainage)  usually  will  close  in  a  few 
days  without  further  trouble,  and  without  materially  interfering  with 
the  object  for  which  the  graft  has  been  transplanted.  In  all  surgical 
procedures  fat  tissue  should  be  most  carefully  handled  and  it  is  espe- 
cially necessary  to  prevent  bruising  when  free  fat  grafts  are  to  be  used. 

In  experimental  work  I  have  found  that  autofat  grafts  are  much 
more  satisfactory  than  isografts,  although  a  small  amount  of  the  iso- 
graft  seems  to  survive.  Clinically  also  this  has  proved  true  when 
isofat  grafts  have  been  used. 

Subcutaneous  fat  is  the  ordinary  source  of  supply,  and  is  usually 
abundant  in  the  abdominal  wall,  the  buttock,  or  the  thigh.  Never- 
theless, within  the  last  year  I  have  operated  on  two  patients  requiring 
pedunculated  skin  and  fat  flaps  (who  were  apparently  well  nourished), 
but  when  the  flap  was  raised  from  the  abdominal  wall  no  subcutaneous 
fat  was  found. 

Omental  fat  has  been  used  successfully,  but  one  would  hardly  feel 
justified  in  opening  the  abdomen  for  the  sole  purpose  of  obtaining 
material  for  a  fat  graft. 

Masses  of  fat  may  be  shifted  or  rolled  (in  favorable  locations),  on 
pedicles  to  fill  in  adjacent  defects  and  in  this  way  better  blood  supply 
is  assured.  Large  masses  of  fat  attached  to  a  pedunculated  skin  flap 
may  be  shifted  where  necessary.  This  method  is  most  useful  both  for 
filling  a  defect  and  in  covering  the  area  with  good  skin  at  the  same  time. 
It  is  often  employed  when  tendons  are  tied  down  by  dense  scar  to  the 
bones,  and  then  after  the  circulation  of  the  flap  is  assured  the  tendons 


THE  TRANSPLANTATION  OF  OTHER  TISSUES  IO5 

are  loosened  and  either  passed  through  tunnels  in  the  fat,  or  are  placed 
in  grooves,  the  edges  of  which  are  sutured  so  as  to  surround  them. 
Newly  made  tendons  may  also  be  passed  through  tunnels  in  the  fat, 
thus  avoiding  adhesions. 

Free  fat  grafts  have  been  used  by  Morestin  and  others  in  filling  the 
orbit  after  enucleation  of  the  eye;  in  defects  left  by  destruction  of  the 
malar  bones;  in  skull  defects  to  prevent  adhesions;  for  filling  bone  de- 
fects, and  in  many  other  instances  in  which  deformities  were  present. 

Fat  is  often  placed  around  nerves  when  adhesions  are  feared.  It 
may  be  said  that  fat  is  a  useful  material  in  many  plastic  cases.  It  heals 
without  irritation,  and  is  apparently  permanent.  The  relative  size  of 
the  fat  graft  depends  more  or  less  on  the  adiposity  of  the  individual. 
Strandburg  reports  an  interesting  case  of  a  girl,  12  years  old,  in  which 
a  pedunculated  flap  of  skin  and  fat  from  the  abdominal  wall  was  trans- 
planted, for  the  relief  of  a  defect  on  the  back  of  the  hand.  But  18 
years  later  when  the  patient  had  become  very  obese,  it  was  found  that 
the  flap  on  the  hand  had  also  increased  in  size  in  proportion  to  the 
great  increase  of  the  abdominal  wall,  and  his  plate  shows  that  the 
increase  was  much  more  marked  than  the  increase  noted  in  the  tissues 
of  the  hand  and  arm  adjacent  to  the  flap.  I  have  had  patients  who 
have  become  quite  obese  several  years  after  the  transplantation  of  such 
a  flap,  but  have  noticed  no  such  excessive  growth. 

Wederhake  reports  a  method  of  utilizing  human  fat  which  after 
suitable  preparation  and  sterilization  is  in  a  liquid  state  and  can  be  in- 
jected h^-podermically.  He  has  employed  it  to  raise  depressed  and 
adherent  scars;  to  pad  the  skin  over  bony  prominences;  for  detaching 
nerve  adhesions;  for  dissolving  cicatricial  tissue. 

I  have  as  yet  had  no  opportunity  to  use  liquified  fat.  but  if  further 
experience  justifies  the  author's  optimistic  report  the  many  advantages 
of  the  method  are  obvious. 

Transplantation  of  Mucous  Membrane 

The  free  transplantation  of  mucous  membrane  is  far  from  satis- 
factory, and  equally  good  results  may  be  obtained  by  the  use  of  thin 
Ollier-Thiersch  grafts.  If  mucous  membrane  is  necessary  and  is  availa- 
ble, it  is  best  to  use  pedunculated  flaps,  as  the  chances  of  success  are 
much  greater.  As  a  rule  skin  should  be  replaced  by  skin,  and  mucous 
membrane  by  mucous  membrane,  but  it  is  often  impossible  to  obtain 
a  suflicient  quantity  of  mucous  membrane,  and  in  these  cases  the  use 


Io6  PLASTIC  SURGERY 

of  pedunculated  flaps  of  hairless  skin  turned  into  the  mouth  or  bladder 
is  satisfactory.  In  time  these  skin  flaps  assume  the  characteristics, 
with  more  or  less  the  appearance  of  mucous  membrane,  and  adjust 
themselves  kindly  to  their  new  environment. 

When  a  flap  of  mucous  membrane  is  used  to  replace  the  skin,  it 
never  assumes  the  character  or  appearance  of  the  skin.  This  may  be 
especially  noticed  in  operations  around  the  mouth. 

Transplantation  of  Muscle 

In  plastic  surgery  free  muscle  transplants  are  not  practicable,  be- 
cause degeneration  and  necrosis  of  muscle  substance  and  progressive 
substitution  of  the  transplant  by  scar  tissue  follow.  As  a  consequence 
the  use  of  muscle  is  entirely  confined  to  pedunculated  flaps  for  filling 
defects,  such  as  bone  cavities.  Only  muscle  flaps  that  have  their  own 
vessels  and  nerves  are  successful. 

The  temporal  muscle  is  frequently  used  for  this  purpose,  and  has 
been  shifted  backward  to  fill  in  the  mastoid  excavation  after  radical 
mastoid  operations.  Morestin,  as  well  as  H.  D.  Gillies,  has  used  a 
flap  of  temporal  muscle  to  fill  a  depression  left  by  the  destruction  of  the 
malar  bone  in  war  wounds. 

Transplantation  of  Tendons 

In  plastic  surgery  the  transplantation  of  tendons  is  confined  either 
to  tendon  lengthening  in  contractures  of  the  hand  or  the  hamstring 
muscles,  and  to  occasional  free  tendon  transplantation.  Free  tendon 
grafts  from  the  peroneal  tendon,  or  from  split  tendons,  may  be  success- 
fully transplanted  to  fill  in  tendon  defects.  New  tendons  may  be  made 
by  tubes  of  fascia,  or  by  utilizing  the  band  of  scar  tissue  connecting 
tendon  stumps.  If  possible  the  new  tendon  should  be  inserted  through 
a  tunnel  in  the  soft  parts.  If  this  is  not  at  once  possible,  the  scar 
should  be  excised,  and  the  area  covered  with  a  pedunculated  flap,  or  a 
graft  of  whole-thickness  skin,  and  tunneling  be  subsequently  done. 
Early  passive  motion  is  important  in  order  to  avoid  adhesions. 

Transplantation  of  Nerves 

Nerve  grafting  is  hardly  worth  trying,  the  ultimate  result  is  always 
unsatisfactory.     End-to-end  suture  is  the  method  of  choice,  and  this 


THE  TRANSPLANTATION  OF  OTHER  TISSUES  I07 

may  be  done  successfully  even  where  considerable  stretching  is  required 
before  the  ends  can  be  approximated.  It  is,  of  course,  necessary  to 
remove  all  scar  tissue  before  suturing.  The  nerve  ends  must  be 
handled  with  the  greatest  gentleness,  and  they  should  be  sutured 
accurately  and  without  rotation. 

Persistence  of  Vitality  of  Transplantable  Tissues 

Martin,  in  his  series  of  experiments,  found  that  none  of  his  skin 
grafts  lived  and  were  effective  after  io8  hours  in  "free  air"  at  a  tem- 
perature of  nearly  o°C.  (32°F.),  but  were  successful  after  as  much  as 
96  hours  in  free  air.  When  kept  in  hermetically  sealed  tubes,  or  con- 
lined  air,  under  the  same  temperature  conditions,  the  grafts  could  be 
successfully  transplanted  after  io8  hours.  Where  the  temperature  was 
6^C.  (42.8°F.)  the  limits  were  82  hours  in  free  air,  and  96  hours  in 
confined  air.  At  i2°C.  (53.6°F.)  the  limits  were  72  hours  in  free  air, 
and  84  hours  in  confined  air. 

At  i5°C.  (59°F.)  ^the  limits  were  60  hours  in  free  air,  and  72  hours 
in  confined  air. 

At  2o°C.  (68°F.)  the  limits  were  36  hours  in  free  air,  and  36  hours 
in  confined  air. 

At  28°C.  (82.4°F.)  the  limts  were  6  hours  in  free  air,  and  7  hours  in 
confined  air,  respectively. 

He  came  to  the  conclusion  that  cold  favored  the  success  of  the  trans- 
plant and  heat  was  unfavorable  and  caused  a  shorter  duration  of  vitality. 
He  also  concluded  that  moisture  hastened  decomposition,  smaller 
masses  lived  longer  and  grafts  were  best  preserved  in  hermetically 
sealed  tubes  at  low  temperature.  It  must  be  remembered  that  these 
experiments  were  made  before  the  days  of  asepsis. 

Brewer  was  able  to  use  successfully  Reverdin  grafts  obtained  from 
skin  removed  from  a  cadaver  as  long  as  36  hours,  but  not  longer. 

The  skin  of  amputated  limbs  has  also  been  successfully  transplanted 
from  36  to  96  hours  after  amputation.  I  have  successfully  transplanted 
on  to  healthy  undisturbed  granulations  pieces  of  whole-thickness  skin 
(taken  from  a  leg  18  hours  after  amputation),  at  various  intervals  up  to 
30  days.  The  superficial  portions  of  the  grafts  kept  over  48  hours 
sloughed  and  only  the  bases  adhered.  Some  of  the  grafts  were  several 
centimeters  in  diameter.  This  skin  was  kept  in  an  ordinary  ice  chest  in 
a  sterile  jar  plugged  with  cotton,  containing  a  gauze  sponge  wet  with 
normal  salt  solution.     I  have  observed  that  whole-thickness  grafts 


Io8  PLASTIC  SURGERY 

which  are  to  be  preserved  for  any  length  of  time  will  take  better  if  the 
subcutaneous  fat  is  allowed  to  remain  intact  and  not  removed  until  the 
time  the  graft  is  needed,  and  then  the  fat  is  removed. 

Girdner  successfully  grafted  skin  from  a  cadaver  6  hours  after 
death.     Many  others  have  also  obtained  grafts  in  this  way. 

Wentscher  grafted  successfully  pieces  of  skin  kept  for  from  7  to 
14  days  in  sterile  tubes  vnih  moist  salt  gauze  and  cotton  plug,  and  was 
able  to  demonstrate  mitosis.  He  concluded  that  grafts  can  be  used 
with  safety  from  24  to  48  hours  after  cutting,  but  usually  not  longer 
than  48  hours. 

Ljungren  grafted  with  success  pieces  of  skin  kept  in  sterile  ascitic 
fluid  for  from  2  days  to  3  months;  the  microscope  showed  that  the 
epithelium  had  multiplied  by  karyokinesis. 

Burkhart  found  that  grafts  lost  nothing  in  \dtality  if  applied  within 
24  hours  after  being  cut.  either  on  fresh  wounds,  or  on  undisturbed 
granulations.  In  cases  in  which  there  was  much  bleeding,  he  applied 
the  grafts  24  hours  later,  after  all  hemorrhage  had  ceased.  This  has 
also  been  my  experience,  especially  wdth  whole-thickness  grafts.  Burk- 
hart obtained  partial  success  with  grafts  preserved  8  days  in  a  moist 
chamhier,  and  12  days  in  a  dry  chamber. 

Dried  epidermic  scales  have  been  successfully  transplanted  418 
days  after  removal  from  the  patient. 

Tufher  in  1910  and  191 1,  preserved  in  cold  storage  in  petrolatum, 
bone.  fat.  cartilage  and  periosteum,  which  he  had  taken  from  amputated 
limbs.  These  tissues  were  kept  for  from  a  few  hours  to  two  months, 
and  were  successfully  transplanted  for  one  purpose  or  another. 

In  191 1  ]\Iagitot  preserved  an  eye  which  had  been  extirpated  for 
glaucoma,  for  8  days  in  human  serum  at  a  temperature  of  4°C.  (39.2°F.). 
He  then  used  a  piece  of  the  cornea  of  this  eye  to  fill  a  defect  made  by 
the  excision  of  a  scar  on  the  cornea  of  a  man  whose  eye  had  been  burned. 
The  graft  lived,  and  7  months  later  was  transparent  so  that  the  patient 
could  see  through  it. 

Carrel  in  1911  experimented  with  the  tissues  of  an  infant  who  had 
died  at  birth.  Several  hours  after  death  the  body  was  washed  with 
soap  and  water,  followed  by  ether.  Dermo-epidermic  grafts  and  flaps 
of  skin  were  removed  and  washed  in  Ringer's  solution.  Bones  were 
also  secured.  Some  of  the  tissues  were  placed  in  tubes  containing 
warmed  sterile  petrolatum  and  others  in  tubes  of  Ringer's  solution. 
All  were  kept  in  a  refrigerator  at  a  temperature  of  3°C.  (37.4°F.)  for 
from  a  few  hours  to  7  weeks.     The  skin  was  successfully  used  for  graft- 


THE  TRANSPLANTATION  OF  OTHER  TISSUES  IO9 

ing  ulcers.  After  five  months  the  tissue  in  petrolatum  was  histolog- 
ically normal.  After  a  few  weeks  the  tissue  in  Ringer's  solution  began 
to  disintegrate.  ^ 

My  own  experience  has  been  limited  to  the  preservation  of  skin, 
fascia,  tendon,  bone  and  cartilage.  All  of  these  tissues  may  be  pre- 
served by  simple  methods,  the  ordinary  petrolatum  used  by  Carrel 
being  probably  the  simplest  and  best  preserving  medium,  stored  at  a 
temperature  of  about  3°C.  (37.4°F.). 

This  brings  up  the  question  of  the  feasibility  of  isografts.  Lexer  at 
the  191 1  Meeting  of  the  German  Surgical  Congress,  and  again  before 
the  International  Society  of  Surgery,  April  15,  1914,  made  the  state- 
ment that  isoskin  grafts  were  never  successful,  and  that  none  of  them 
ever  lasted  longer  than  three  weeks.  I  cannot  agree  with  him,  as  I 
have  seen  a  number  of  permanently  successful  isoskin  grafts.  On  the 
other  hand,  Lexer  said  he  had  successfully  transplanted  whole  isojoints, 
with  good  results,  which  hardly  seems  consistent. 

The  limitations  of  the  preservation  of  tissues  for  future  transplanta- 
tion have  not  been  fully  worked  out,  but  the  possibilities  are  fascinating. 

BIBLIOGRAPHY 

Transplantation  of  Tissues 

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BoRST,  M.     "I.  Verhandl.  d.  deutsch.  path.  Gesellsch."     Jena,  1914,  -xvii,  300. 

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^  Rhijier's  Solution. — Sodium  chlorid 0.7      per  cent. 

Potassium  chlorid 0.03    per  cent. 

Calcium  chlorid 0.025  per  cent. 

Water 


no  -  PLASTIC  SURGERY 

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Transplantation  of  Fascia 

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Transplantation  of  Bone 

Beraejd,  L.     "Presse  med.,"  1917,  281. 

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Gallie,  W.  E.  &  Robertson,  D.  E.     "J.  A.  M.  A.,"  April  20,  1918,  1134. 
Groves,  E.  W.  H.     "Brit.  J.  Surg.,"  Oct.,  1917,  185. 
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"Med.  Rec."     New  York,  1916,  xc,  498. 
Ollier.     "Traite  Experimental  et  Clinique  de  la  Regeneration  des  Os."     Paris,  1867. 


THE  TRANSPLANTATION  OF  OTHER  TISSUES  III 

Phemister,  D.  B.     "Intermit.  Abst.  Surg.,"  April,  1914,  33,3- 
Schmieden  &  Erkes.     "Arch.  f.  klin.  Chir.,"  1912,  c,  Nr.  i. 
Streissler,  K.     "Beitr.  z.  klin.  Chir.,"  Bd.  71,  1911,  i. 
TuRCK,  R.  C.     "x\.  J.  Surg.,"  Nov.,  1914,  409. 

Transplantation  of  Cartilage 

Davis,  J.  S.     "Anns.  Surg.,"  Nov.,  1916,  519. 

Fantozzi,  G.     "Rivista  Critica  di  Clinica  Med."     Florence,  Oct.  26,  1918,  481. 
Imbert,  L.,  Lheureux  &  Rouslacroix.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1916, 
xliii,  1856. 

"Rev.  de  Chir."     Paris,  1916,  xxxv,  in. 
MoRESTiN,  H.     "Bull,  et  mem.  Soc.  de  Chir."     Paris,  1915,  xli,  1994. 

"Bull,  et  mem.  Soc.  de  Chir."     Paris,  1916,  xlii,  424. 

"Bull,  et  mem.  Soc.  de  Chir."     Paris,  Feb.,  191 7,  580. 
V.  Tappeinter,  F.  H.     "Arch.  f.  klin.  Chir.,"  1916,  cvii,  479. 


Transplantion  of  Fat 

Caforio,  L.     "Policlin.  Roma,"  191 7,  xxiv,  Sex.  prat.,  490. 

Davis,  C.  B.     "J.  A.  M.  A.,  March  3,  191 7,  705. 

DuBREUiLH,  W.     "Jour,  de  Med.  de  Bordeaux,"  Feb.  15,  1919,  47. 

EsTOR  &  Etienne.     "Rev.  d'orthop."     Paris,  1913,  iv.  No.  3. 

Eloesser,  L.     "J.  A.  M.  A.,"  Jan.  30,  1915,  426. 

Galpern,  J.     "Vrach.  Gaz.  St.  Petersb.,"  1913,  .xx,  592. 

Kanavel,  a.  R.     "Tr.  Amer.  Surg.  Assn.,"  1916,  x.xxiv,  434. 

"J.  Missouri  Med.  Assn.,"  191 7,  xiv,  333. 
Klopfer,  E.     "Beitr.  z.  klin.  Chir.,"  Lxxxiv,  Nr.  3. 
Lewis,  D.     "Surg..  Gyne.  &  Obst.,"  Feb.,  191 7,  127. 
Lexer.     "Klin.  Therapeut.  Wchnschr.,"  191 1,  Nr.  3. 
Makkas.     "Beitr.  z.  klin.,  Chir.,"  1912,  Ixxvii,  523. 

MoRESTix,  H.     "Bull,  et  mem.  Soc.  de  chir.  de  Par.,"  1915,  n.  s.  xli,  1631. 
Perimoff,  V.     "Med.  Obozr."     Moskow,  1913,  Ixxix,  763. 

Rehn,   E.     "Verhandl.   d.   Gessellsch.   deutsch.  Naturf.   u.  Aerzte,    Konigsb."     Leipsic, 
1911,  Ixxxii,  121. 

"Archiv  f.  klin.  Chir.,"  xcviii,  Nr.  i. 
Risley,  E.  H.     "Surg.,  Gyne.  &  Obst.,"  Jan.,  1917,  85. 
Stewart,  F.  T.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  191 7,  141. 
Wederhake.     "Berlin  k.  Wchnschr.,"  1918,  Bd.  55,  47. 

Transplantation  of  Mucous  Membrane 

HoHMEiER,  F.     "Zent.  f.  Chir.,"  Nr.  29,  July  22,  1911,  27.     Suppl. 

Transplantation  of  Muscle 

AsKANZY,  M.     "Wien.  med.  Wchnschr.,"  1912,  Ixii,  27. 
CoNR.AD,  M.     "Inaug.-Diss."     Berlin,  1912. 
Erlacher,  p.     "Zent.  f.  Chir.,"  Nr.  15,  1914,  625. 
"Archiv  f.  klin.  Chir."     Berlin,  cvi,  Nr.  2. 


112  PLASTIC  SURGERY 

Gillies,  H.  D.     "St.  Bartholomew's  Hosp.  Jour.,"  May,  1917,  79. 
GoEBEL,  R.     "Deut.  med.  Wchnschr.  Leipz.  u.  Berl.,"  191 2. 

"Deut.  Zeit.  f.  Chir.,"  cxxii,  1913,  318. 
HiLDEBRANDT.     "Thera.  Monatsh,"  Berlin,  Nov.,  1910,  Nr.  11. 
Iglauer,  S.     '  The  Laryngoscope,"  May,  1913,  No.  5. 
Kroh,  F.     "Deut.  Zeit.  f.  Chir.,"  cxx,  302. 

Lawen.     "Verhandl.  d.  deutsch.  Gesellsch.  f.  Chir."     Berlin,  1912,  xlii,  37. 
Levy,  R.     "Beitr.  z.  klin.  Chir.,"  May,  1914,  666. 
Mantelli.     "Zent.  f.  Gynak."     Leipsic,  Nov.  22,  1910,  xxiv,  1481. 
NiKOLSKY,  A.     "Russky.  Vrach."     Petrograd.,  xvi,  No.  11,  252. 
Serajfini,  G.     " Sperimentale,  Firenze,"  1917,  Ixxi,  223. 

Transplantation  of  Tendons 

Bailleul,  L.  C.     "Paris  Med.,"  1915-16,  xvii,  287. 

Delorme.     "Bull.  d.  I'academie  de  med."     Paris,  Nov.  19,  1918,  452. 

Gaudier  &  Swynghdauw.     "Echo.  med.  du  Nord,"  191 1,  xv,  289,  Lille. 

Henderson,  M.  S.     "J.  A.  M.  A.,"  May  28,  1918,  1456. 

Lexer.     "Kor.-Bl.  d.  allg.  arztl.  Ver.  v.  Thuringen."     Jena,  191 2,  xli,  389. 

"Archiv  f.  klin.  Chir.  xcviii,  Nr.  3. 
Nageotte,  J.  AND  Sencert,L  .     "Bull.  d.  I'academie  de  med."     Paris,  Nov.  12,  1918,  448. 
TiMMER.     "Zent.  f.  Chir.,"  July  20,  1912,  995. 

Transplantation  of  Nerves 

CoRBETT,  J.  F.     "internat.  Abst.  Surg.,"  Feb.,  1919,  105. 

Haberland,  H.     "Zent.  f.  Chir.,"  Nr.  4,  1916,  74. 

Heineke.     "Zent.  f.  Chir.,"  Nr.  11,  1914,  465. 

Joyce,  J.  L.     "Brit.  Jour.  Surg./'  Jan.,  1919,  418. 

Manoury  (and  others).     "Bull.  Med."     Paris,  1918,  xxxii,  pp.  411;  426;  436. 

TuTTLE,  H.  K.     "Jour.  Amer.  Med.. Assn.,"  July  5,  1913,  15. 

Zesas,  D.  G.     "  Centralbl  f .  d.  Grenzgebiete  d.  Med.  &  Chir."     Jena.,  Feb.  19,  1914,  Nr.  2. 

Vitality  of  Transplantable  Tissues 

Brewer.     "Med.  Rec."     N.  Y.,  May  6,  1882,  vol.  21,  483. 
Carrel,  A.     "J.  A.  M.  A.,"  Aug.  17,  1912,  523., 

"J.  A.  M.  A.,"  Nov.  II,  1911,  1611. 
GiRDNER.     "Med.  Rec."     N.  Y.,  July  30,  1881,  vol.  20,  119. 
Guthrie.     "J.  A.  M.  A.,"  March  12,  1910,  832. 

"Heart."     London,  1910,  ii,  115. 
Lambert,  R.  A.     "Jour.  Exp.  Med.  N.  Y.,"  1913,  xviii,  406. 
Magitot,  a.     "Pro.  Med.,"  June  i,  191 2,  364. 

"J.  A.  M.  A.,"  July  6,  1912,  18. 
Martin.     "These  de  Paris,"  1873. 

Pozzi,  S.     "Bull,  de  I'Academie  de  Med."     Paris,  June  18,  191 2,  Ixvi,  26. 
Tuffier.     "Bull,  et  mem.  de  la  Soc.  de  chir.  de  Paris,"  xxxvi,  Feb.  22,  1910. 
Wentscher.     "Deutsche  Ztschr.  f.  chir.,"  1903,  Bd.  70,  21. 


CHAPTER  VI 
PEDUNCULATED  FLAPS 

i-  In  the  present  war  there  have  been  many  whose  wounds  have  caused 
the  loss  of  skin  and  subcutaneous  tissue,  and  even  deeper  tissues,  in 
situations  which  ultimately  will  require  a  resistant  elastic  healing 
before  a  satisfactory  functional  result  can  be  obtained.  Many  of 
these  defects  can  be  properly  remedied  only  by  the  use  of  pedunculated 
flaps  of  skin  and  subcutaneous  tissue  (Figs.  loo  and  loi). 

By  a  pedunculated  flap  I  mean  a  mass  of  tissue,  usually  the  skin 
and  subcutaneous  fat,  which  is  raised  from  its  bed  but  is  left  attached 
to  the  surrounding  skin  at  a  selected  portion  of  its  periphery.  There 
is  another  type  of  pedunculated  flap  with  a  pedicle  of  subcutaneous 
tissue,  the  skin  being  cut  all  around  it.  It  was  first  used  by  Gersuny 
and  is  useful  in  closing  defects  in  the  mucous  membrane.  Esser  has 
recently  described  similar  flaps,  calling  them  "Island  Flaps." 

Through  this  skin  or  subcutaneous  attachment,  called  the  pedicle, 
the  flap  receives  its  blood  supply.  The  flap  can  be  shifted,  as  far  as  its 
pedicle  will  permit,  to  fill  the  defect. 

Pedunculated  flaps  may  be  obtained  from  tissue  in  the  neighborhood 
of  the  defect,  or  from  a  distant  part.  There  may  be  a  single,  or  a  double 
pedicle. 

There  are  three  general  methods  of  obtaining  pedunculated  flaps, 
(i)  The  French  method  of  sliding  flaps  from  adjacent  tissue  in  which 
process  there  is  little  or  no  torsion  of  the  pedicle.  (2)  The  Indian  method, 
in  which  the  flap  is  obtained  from  the  immediate  neighborhood  of  the 
defect  and  is  shifted  into  its  new  position  by  more  or  less  twisting  of  the 
pedicle.  The  pedicle  of  the  flap  may  be  adjacent  to  the  defect,  or  it 
may  be  necessary  for  the  pedicle  to  bridge  over  normal  tissue  before 
the  flap  can  be  placed  in  its  new  position.  (3)  The  Italian  or  Taglia- 
cotian  method,  in  which  the  flap  is  obtained  from  a  distant  part,  usually 
from  the  arm. 

A  way  of  further  utilizing  pedunculated  flaps  was  described  by  Dr. 

W.  S.  Halsted  in  1898.     He  reported  a  method  which  he  had  used  in 

the  treatment  of  an  extensive  burn  of  the  cheek,  neck  and  arms,  and  he 

spoke  of  the.  method  as  "waltzing"  the  flap.     He  says,  "None  of  the 

8  113 


114 


PLASTIC  SURGERY 


M     ^, 


;      I&       \ 


Outlines  showing  the  skin  regions  supplied  by  different  arteries.  (Manchot.) 
Fig.  100. — i.  The  superior  superficial  epigastric  artery;  2,  The  inferior  superficial 
epigastric  artery;  3,  The  superior  and  inferior  superficial  epigastric  arteries;  4,  The  external 
pudic  artery;  5,  The  dorsal  artery  of  the  penis;  6,  The  perforating  branches  of  the  inter- 
costal arteries;  7,  The  perforating  branches  of  the  lumbar  arteries;  8,  The  superficial  cir- 
cumflex iliac  artery;  9,  The  profunda  femoris  and  internal  circumflex  arteries;  10,  The 
femoral  artery;  11,  The  arterial  anastomosis  around  the  patella;  12,  The  anterior  tibial 
artery;  13,  The  posterior  tibial  artery;  14,  The  popliteal  artery;  15,  The  superior  and  long 
thoracic  arteries;  15a,  The  acromiothoracic  artery.  16,  The  perforating  branches  of  the 
internal  mammary  artery;  17,  The  thyroid  axis;  18,  The  superior  thyroid  artery;  19,  The 
anterior  circumflex  artery;  20,  The  brachial  artery;  21,  The  inferior  profunda  artery; 
22,  The  radial  artery;  23,  The  median  artery;  24,  The  ulna  artery. 


PEDUNCULATED  FLAPS 


11^ 


Outlines  showing  the  skin  regions  supplied  by  different  arteries  (continued) .  (Manchot.) 
Fig.  ioi. — i,  The  dorsal  branches  of  the  intercostal  arteries;  2,  The  dorsal  branches  of 
the  lumbar  arteries;  3,  The  dorsal  branches  of  the  sacral  arteries;  4,  The  posterior  perforat- 
ing branches  of  the  intercostal  arteries;  5.  The  posterior  perforating  branches  of  the  lumbar 
arteries;  6,  The  thyroid  axis;  a.  Superficial  cervical  artery;  b.  Suprascapular  artery;  c, 
Transversalis  Colli  artery;  7,  The  posterior  circumflex  artery;  8.  The  dorsalis  scapulae 
artery;  9,  The  radial  recurrent  artery;  10,  The  inferior  profunda  artery;  11,  Arterial  anas- 
tomosis around  the  olecranon;  12.  The  radial  artery;  13,  The  ulna  artery;  14,  The  anterior 
and  posterior  interosseous  arteries;  15.  The  gluteal  artery;  16,  The  comes  nervi  ischiadici 
artery;  17,  The  internal  pudic  artery;  18,  The  obturator  artery;  19,  The  perforating 
branches  of  the  profunda  femoris  artery;  20.  The  popliteal  artery;  21,  The  anterior  and 
posterior  tibial  arteries. 


Il6  PLASTIC  SURGERY 

original  attachments  of  the  last  flap  which  we  used  have  been  preserved. 
The  flap  has  twice  been  twisted  upon  itself,  first  upon  a  small  pedicle 
of  skin,  original  tissue  we  may  call  it,  and  secondly  upon  a  Kttle  broader 
pedicle  of  cultivated  cicatricial  tissue.  The  flap  has  probably  made  a 
complete  revolution."  In  my  own  work  I  have  found  it  possible  to 
shift  masses  of  skin  and  subcutaneous  fat  gradually  into  positions  far 
removed  beyond  the  restriction  of  the  original  pedicle. 

THE   TRANSFERENCE   OF   THE   FLAP 

The  transference  of  the  flap  may  be  single,  that  is  when  it  is  placed 
directly  on  the  defect.     This  may  be  done  whether  the  flap  is  from  the 

neighborhood   or  from  a    distant   part, 
/  /  V.  either  immediately  after  cutting  (fresh), 

^■^  I     ^s^j^^  or  after  granulations  have  formed. 

The  transfer  may  be  multiple,  or  by 
successive  migration,  that  is  where  it  is 
impossible  on  account  of  its  position  to 
place  the  flap  directly  on  the  defect.  For 
instance,  in  cases  in  which  it  is  advisable 
.^^    '^  ^^rr^J\^^  ]   to  use  a  flap  from  the  abdominal  wall  to 

repair  a  chin,  the  flap  is  raised  and  grown 
into  an  incision  in  the  forearm  or  hand. 
Then,  after  the  circulation  has  been  es- 
tablished from  the  forearm,  the  pedicle 
is  amputated  from  the  abdomen  and  the 
flap  is  transferred  on  the  forearm  to  the 
Pig.   102.— Double  pedicied  bridge  chin.     In  due  time  the  flap  is  cut  away 

flap  showing  skin  sutured  beneath  it.  i         r  i     •       •  t         i 

If  skin  edges  cannot  be  approxi-  ^^om  the  forearm  and  IS  immediately 
mated    the  raw  surface  may  be  fitted  into  its  new  bed.     By  this  method 

transfer  has  also  been  made  from  abdo- 
men to  chest,  to  neck,  to  chin,  and  in  other  combinations.  It  should 
be  emphasized  at  the  onset  that  the  raw  surface  of  the  flap  necessarily 
granulates  and  the  shrinkage  is  considerable. 

If  an  abdominal  flap  be  used  with  a  pedicle  on  one  side  of  the  mid- 
line, it  is  advisable,  on  account  of  the  arterial  distribution,  that  the 
skin  of  the  flap  be  taken  from  the  same  side.  This  is  unnecessary  where 
the  pedicle  includes  skin  on  both  sides  of  the  midline. 

The  area  from  which  the  pedunculated  flap  is  taken  may  be  closed 
with  sutures  if  the  skin  is  lax,  or  after  undercutting  and  sliding.     If 


PEDUNCULATED  FLAPS 


117 


closure  is  not  possible  on  account  of  the  size  of  the  area,  it  may  be 
covered   with   skin  grafts,  preferably  of   the  Ollier-Thiersch  variety 

(Figs.  102  and  103). 


Fig.   103. — Methods  of  dealing  with  defects  left  by  the  removal  of  pedunculated  flaps  from 

the  abdominal  wall. 

1.  A  broad  pedicled  flap  was  raised  and  transplanted  into  the  foreamit  and  after  the 
pedicle  was  severed  the  defect  was  grafted  with  Ollier-Thiersch  grafts.  The  photograph 
was  taken  two  weeks  after  grafting  and  shows  the  wound  not  quite  healed. 

2.  A  flap  with  a  comparatively  narrow  pedicle  was  raised  and  was  implanted  into  a  hand 
defect.     After  the  pedicle  was  cut  the  edges  were  drawn  together  and  sutured. 

Both  of  these  methods  are  satisfactory. 

TYPE  OF  FLAP 

Pedunculated  flaps  may  be  simple,  where  only  the  skin  and  subcu- 
taneous tissue  is  used,  or  compound  where  periosteum,  bone,  or  carti- 
lage is  included  in  the  flap. 


E_3 


Ld 


I  234 

Fig.   104. — Methods  of  making  double  thickness  flaps  with  epithelium  on  both  sides.   {Cole.) 

1.  Outline  of  incisions.     The  area  between  the  dotted  lines  is  the  portion  of  the  flap  to 
be  lined. 

2.  The  flap  raised.     The  wings  A  and  B  being  turned  in  and  sutured. 

3.  Outline  of  flap,  which  is  folded  on  itself  at  the  dotted  line. 

4.  The  free  end  of  the  flap  A  folded  and  secured.     These  are  old  and  useful  methods. 

In  compound  flaps  the  periosteum  or  bone  may  be  taken  up  with  the 
flap  without  being  separated  from  the  soft  parts,  as  when  periosteum 


ii8 


PLASTIC  SURGERY 


and  bone  are  raised  from  the  frontal  bone  in  certain  rhinoplastic 
operations,  or  when  a  portion  of  the  clavicle  is  raised  with  a  flap  from 
the  neck  to  repair  a  jaw  defect. 


123 

Pig.    105. — Method  of  making  a  flap  with  epithelium  on  both  sides.    (Cole.) 

1.  The  dotted  lines  indicate  the  area  to  be  lined.  The  triangles  A  and  B  are  to  be  folded 
under  and  sutured. 

2.  Shows  this  accomplished  and  wound  nearly  closed.  The  double  surfaced  flap  is 
stretched  on  the  skin  of  the  neck  and  held  by  sutures. 

3.  The  pedicle  extended  upward  and  the  flap  in  position.  The  neck  defect  may  be 
partially  sutured  and  the  rest  of  the  pedicle  should  be  utilized  to  close  the  upper  portion  of 
the  neck  defect. 

When  cartilage  is  used,  a  shaped  section  of  cartilaginous  rib  is 
ordinarily  transplanted  to  the  desired  location  in  the  future  flap,  and 
after  it  has  become  established  in  its  new  position  (3  to  6  weeks), 
the  flap  containing  the  cartilage  is  raised  and  shifted  to  the  defect. 


Pig.    106. — Method  of  making  a  flap  with  epithelium  on  both  sides.      (Cole.) 

1.  Outline  of  the  flaps. 

2.  The  flap  from  the  chest  is  turned  upward  and  is  sutured  under  the  neck  flap. 

3.  The  pedicle  of  the  chest  flap  is  cut  and  the  double-faced  flap  with  its  pedicle  on  the 
neck  is  shifted  where  desired.  This  method  is  advantageous  where  it  is  not  possible  to 
obtain  sufflcient  tissue  by  the  use  of  one  pedicle. 

This  method  is  also  used  when  it  is  desirable  to  use  free  bone,  or  free 
periosteum  in  a  flap. 

Double-faced  Flaps. — If  a  pedunculated  flap  of  any  considerable 
size  is  used  to  construct  a  lip  or  eyelid,  or  to  fill  a  defect  inside  the 


PEDUXCULATED  FLAPS 


119 


mouth,  an  epithelial  and  not  a  raw  surface  should  be  placed  inside  the 
cavity.  Unless  this  precaution  is  taken  contracture  will  take  place, 
because  the  mucous  membrane  does  not  spread  with  sufficient  rapidity 
to  cover  a  raw  surface  of  any  size  in  time  to  prevent  contracture. 

For  example,  when  the  reconstruction  of  the  lower  lip  is  contem- 
plated and  lateral  flaps  of  the  full  thickness  of  the  cheek  cannot  be 
used,  it  is  necessary  to  have  a  flap  which  is  covered  with  epithelium 
on  both  sides.     This  may  be  accomplished  by  grafting  the  under  surface 


Fig.    107. — Method  of  folding  an  arm  flap  on  itself  in  order  to  obtain  epithelium  on  both 

sides. 

1.  The  flap  has  been  raised  from  the  arm  and  folded  on  itself.  Photograph  taken 
two  weeks  later.  The  double-faced  flap  is  stretched  on  a  gauze  covered  wire  frame  to  pre- 
vent unnecessary  contracture. 

2.  The  area  from  which  the  flap  was  raised  covered  with  Ollier-Thiersch  grafts.  Photo- 
graph two  months  later. 


of  the  flap  and  waiting  until  the  healing  is  complete  before  transferring 
the  flap,  as  is  well  described  by  Watts.  Another,  and  in  my  own 
experience  a  better  method  is  to  fold  the  end  of  the  flap  on  itself  and 
allow  the  raw  surfaces  to  heal  together,  after  which  the  transfer  is  made 
in  the  usual  way.  If  a  supporting  substance  is  necessary  in  such  a 
flap,  free  cartilage  may  be  inserted  between  the  raw  surfaces  (Figs. 
104-108). 

According  to  Lefevre,  in  cheek  plastics  Chavannaz  obtained  good 
results  in  two  cases  by  turning  the  raw  surface  of  a  pedunculated  flap 
inside.     Lefevre  did   some  experimental  work  on  dogs  to  prove  this 


I20 


PLASTIC  SURGERY 


point,  and  found  the  results  very  satisfactory,  the  raw  surface  healing 
in  from  1 6  to  30  days. 

My  own  experience  leads  me  to  believe  that  only  flaps  covered  with 
epitheHum  will  prevent  subsequent  contractures  when  turned  inside 
the  mouth. 

Symbiotic  Transplantation. — The  attachment  of  one  person  to  a 
pedunculated  flap  raised  from  another  (which  may  be  called  symbiotic 
transplantation)  has  been  attempted  a  number  of  times,  but  without 
very  satisfactory  results.  Finney  reported  an  unsuccessful  case  of 
this  kind  before  the  American  Surgical  Association  on  June  5,  1909,  and 


Fig.    108. — A  pedunculated  flap  from  the  arm  with  its  pedicle  toward  the  elbow. 

1.  The  flap  raised.  The  defect  on  the  arm  was  immediately  grafted  with  Ollier- 
Thiersch  grafts.  This  flap  was  implanted  into  a  nose  defect  but  did  not  adhere.  Its  under 
surface  was  then  grafted  and  the  patient  allowed  to  go  home  for  six  months. 

2.  The  condition  of  the  arm  and  flap  after  the  patient  returned.  There  has  been  con- 
tracture of  the  grafted  surface  of  the  flap  and  shrinkage  has  taken  place.  The  flap  was 
subsequently  uncurled  and  was  used  with  success  for  the  purpose  desired. 

quoted  Lund,  who  had  had  little  better  success  in  his  own  case.  In  both 
of  these  cases  there  were  unavoidable  complications  which  tended  to 
cause  failure.  The  method  is  even  more  trying  on  the  participants 
than  when  autoplasty  is  practised  with  pedunculated  flaps  from  dis- 
tant parts,  and  for  this  reason  is  not  to  be  recommended.  Neverthe- 
less there  is  no  reason  why  such  a  procedure  should  not  be  successful 
under  favorable  conditions. 

O.  Laurent  reported  four  cases  in  which  he  successfully  used  pedun- 
culated flaps  from  other  persons  for  the  repair  of  extensive  humerus  or 


PEDUNCULATED  FLAPS  121 

femur  defects.  The  donors  and  recipients  were  fastened  together  for 
from  8  to  lo  days.  Excess  bone  in  amputation  stumps,  which  required 
shortening,  was  used  in  each  case,  and  the  results  were  said  to  be 
satisfactory. 

IMPORTANT  SUGGESTIONS 

In  using  pedunculated  flaps  the  following  are  some  points  which 
experience  has  shown  to  be  essential  for  success. 

The  patient  should  be  in  the  best  possible  physical  condition. 
Asepsis  rather  than  antisepsis  should  be  maintained  throughout  the 
operation  and  during  convalescence.  The  tissues  should  be  treated 
with  the  greatest  consideration.  Keen-cutting  instruments  must  be 
used,  in  order  to  avoid  unnecessary  injury  to  the  tissues.  The  flaps 
should  be  handled  with  special  forceps  or  small  sharp  hooks.  All 
hemorrhage  should  be  checked  in  the  area  into  which  the  flap  is  to  be 
transferred.  Accurate  apposition  of  the  sutured  edges  is  desirable 
because  prompt  healing  minimizes  scar  tissue. 

The  sutures  should  be  placed  so  as  to  avoid  tension,  which  always 
jeopardizes  the  success  of  the  flap. 

Pedunculated  flaps  are  especially  valuable  when  a  pad  of  fat  in 
addition  to  the  whole  thickness  of  the  skin  is  required  to  fill  a  defect. 

Flaps  usually  include  the  skin  and  as  much  of  the  subcutaneous 
fat  as  is  needed.  The  fat  should  be  somewhat  thicker  than  is  actually 
necessary  to  fill  the  defect,  because  the  excess  is  cared  for  by  subsequent 
shrinkage. 

The  shape  of  the  flap  must  correspond  fairly  accurately  to  the  defect 
which  it  is  to  cover.  Long-pointed  flaps  should  be  avoided,  on  account 
of  almost  certain  necrosis  of  the  tips.  Thin  flaps  are  so  pliable  that 
they  can  be  easily  adjusted  to  fit  a  defect  of  almost  any  shape.  In 
rhinoplastic  operations  it  is  desirable  to  outline  the  flap  from  a  carefully 
calculated  pattern. 

The  skin  of  pedunculated  flaps  must  be  chosen  with  some  regard  to 
the  character  of  the  skin  surrounding  the  area  into  which  it  is  to  be 
put.  That  from  the  immediate  neighborhood  usually  matches  better 
than  that  from  distant  parts. 

Unless  it  has  been  previously  depilated  a  flap  of  hairs*  skin  should 
never  be  turned  into  the  mouth,  or  any  other  mucous  lined  cavity, 
because  the  hair  will  continue  to  grow  and  will  cause  much  discomfort. 
The  same  rule  to  a  less  extent  holds  good  in  shifting  flaps  of  hairy 
scalp  to  fill  defects  on  hairless  portions  of  the  face.     Recently  P.  P. 


122 


PLASTIC  SURGERY 


Cole  reported  that  he  had  used  a  flap  from  the  hairy  scalp  to  repair 
a  facial  defect  and  that  subsequently  the  hair  was  readily  removed  by 
radiation,  so  that  a  smooth  skin  was  left. 

The  flap  should  be  cut  at  least  one-third  larger  than  the  area  it  is  to 
fill,  as  there  is  always  immediate  shrinkage  in  the  direction  of  the  elastic 
fibers. 

Normal  skin  is  necessary  for  a  successful  flap,  because  any  scar  on 
the  edge  will  usually  slough  and  a  scar  running  across  a  flap  will 
completely  cut  off  the  circulation  beyond  it. 


Fig.    109. — Method  of  shifting  flaps  without  torsion  of  the  pedicles.      iJacobovici.) 
The  dark  lines  indicate  the  incisions  for  raising  the  flaps.      The  dotted  lines  show  the 
positions  into  which  the  flaps  are  shifted. 

Whenever  possible  all  scar  tissue  should  be  excised,  especially  along 
the  edges  to  be  sutured,  as  the  healing  will  be  more  satisfactory  if 
normal  tissues  are  approximated. 

The  pedicle  should  be  as  broad  as  possible,  but  in  all  flaps  which 
are  to  be  twisted  it  should  be  narrower  than  the  body  of  the  flap.  In 
flaps  from  the  immediate  neighborhood  one  should  always  aim  to  have 
the  pedicle  very  close  to  the  loss  of  substance  and,  when  practicable, 
the  long  axis  of  the  pedicle  should  be  in  the  same  direction  as  the  axis 
of  the  flap  in  its  new  direction.  The  pedicle  of  a  flap  should  be  in  the 
same  line  as  the  area  to  be  filled  (Fig.  109). 


PEDUNCULATED  FLAPS 


123 


The  elasticity  of  the  skin  will  allow  a  curved  flap  to  assume  a 
straight  position  without  difliculty. 

As  a  general  rule  the  flap  should  never  be  longer  than  from  two  and 
one-half  to  three  times  the  width  of  the  pedicle,  unless  it  contains  a 


Fig.    1 10. — The  Indian  method  of  using  a  flap  of  adjacent  tissue. 

1.  The  dark  line  indicates  the  outline  of  the  flap  B  to  fill  the  defect  C.  Note  that  the 
flap  B  is  larger  than  C.  The  dotted  line  A  indicates  the  line  of  incision  if  more  freedom  is 
desired  for  the  pedicle. 

2.  The  flap  B  covering  the  defect.  The  raw  surface  from  which  the  flap  is  raised  may- 
be sutured  or  grafted. 

main  artery,  in  which  case  the  pedicle  may  be  much  less  wide  and  the 
flap  less  thick.  However,  a  main  artery  is  not  essential  if  the  pedicle 
is  adequate  and  the  flap  is  thick  enough  to  include  a  number  of  small 
vessels  sufficient  for  its  proper  nutrition. 


Fig.    III. — Methods  of  scarifying  pedunculated  flaps. 

If  the  pedicle  of  a  flap  adjacent  to  the  defect  is  too  short  to  allow 
turning  into  the  defect  without  tension,  the  incision  not  terminating 
in  the  defect  should  be  prolonged  outward  (Fig.  no). 

A  pedicle  should  never  be  notched  at  the  time  of  implantation  in 


124 


PLASTIC  SURGERY 


order  to  make  it  fit  better,  as  there  is  risk  of  impairing  the  circulation. 
If  there  is  puckering  of  the  edges  of  a  pedicle,  it  can  be  adjusted  after 
the  new  circulation  is  assured. 

Twdsting  or  too  much  tension  on  a  pedicle  may  cause  shutting  off 
of  the  circulation  and  gangrene  of  the  flap. 

Occasionally  gangrene  occurs  in  a  flap  which  has  an  excellent  blood 
supply;  this  may  be  due  to  lack  of  drainage  from  the  flap,  or  in  other 
words  the  flap  is  choked  with  the  blood  and  lymph  that  enter  it,  but  are 
unable  to  get  out  promptly.  This  accident  is  especially  to  be  feared 
if  the  pedicle  contains  a  main  artery.  To  overcome  this  danger  C.  H. 
Mayo  suggested  superficial  scarification  of  the  flap  to  allow  surface 


Fig.  112. — Method  of  preparing  a  flap  before  shifting  it  to  its  new  position,  by  raising  its 
body^from  the  underlying  tissues   and  keeping  them   separated   with   paraffined  linen. 

Neither  pedicle  is  severed  at  first,  but  after  a  week  the  extremity  which  is  to  be  the  free 
end  is  separated  by  gradual  notching  on  one  or  both  sides.  In  this  way  the  blood  supply 
of  a  long  narrow  flap  may  be  practically  assured  before  it  is  transplanted. 


drainage  until  proper  vessel  drainage  is  established  (Fig.  in).  This 
procedure  I  have  found  very  satisfactory.  When  a  long  narrow  flap  is 
required  and  there  is  doubt  about  the  blood  supply,  it  is  advisable  to 
raise  the  flap  from  its  bed  but  leave  it  attached  at  each  end  (a  mxcthod 
emphasized  by  Croft,  but  also  practised  by  Tagliacozzi  in  his  original 
operation).  After  the  flap  has  been  raised  it  is  advisable  to  close  the 
skin  beneath  the  flap,  or  else  to  keep  it  separated  from  its  bed  with 
rubber  tissue;  or  the  bed  beneath  the  flap  may  be  grafted  with  Ollier- 
Thiersch  grafts.  After  two  or  three  weeks  one  pedicle  should  be  cut, 
the  granulating  surface  freshened  and  the  flap  transferred  in  the  usual 


PEDUNCULATED  FLAPS  1 25 

manner.  The  other  pedicle  should  be  severed  later  on  (Figs.  112 
and  113). 

Perthes,  in  order  to  attain  the  same  end,  uses  the  following  methods, 
which  have  much  to  recommend  them. 

I.  The  flap  is  more  or  less  completely  marked  out  by  an  incision, 
and  detached  from  the  underlying  tissues.  It  is  then  sutured  back  in 
its  original  position  and  the  wound  is  allowed  to  heal  by  first  intention. 
About  eight  days  later,  or  (if  a  series  of  such  preparatory  incisions  is 
preferred  to  a  single  one)  eight  days  after  the  last  incision,  the  flap  is 
swung  into  its  new  permanent  site.  As  the  circulation  has  been  com- 
pletely interrupted  wherever  the  skin  was  divided,  or  undermined, 
collateral  circulation  by  way  of  the  pedicle  is  stimulated,  whereas  any 


Fig.   113. — Method  of  using  a  long  double  pedicled  flap  for  the  relief  of  a  neck  defect. 

{Croft.) 
The  dotted  lines  indicate  the  extent  of  the  flap  raised  from  its  bed.     The  under  surface 
is  prevented  from  adhering  to  the  underlying  tissues,  but  the  pedicles  are  not  cut.     Later 
the  lower  pedicle  DC  is  divided  and  the  flap  is  shifted  in  to  fill,  the  neck  defect.     This  is 
a  slow  but  sure  method. 

circulation  reestablished  across  the  line  of  incision  and  undermined 
area  is  negligible.  In  this  manner  the  flap  is  assured  of  an  adequate 
blood  supply  through  its  pedicle  before  it  is  transferred.  Another 
advantage  lies  in  the  fact  that  the  flap  does  not  shrink  as  much  as  if  it 
had  been  transferred  at  once  to  its  new  position. 

2.  The  outline  of  the  flap  is  obtained  by  compressing  the  skin  along 
the  lines  to  be  followed  when  it  is  ultimately  cut  and  transferred.  This 
compression  is  effected  by  running  a  large  darning  needle  under  the 
skin  which  covers  all  but  the  ends  of  the  needle.     A  second  needle  is 


126  PLASTIC  SURGERY 

placed  over  the  skin  parallel  with  the  first,  to  the  ends  of  which  it  is 
secured.  The  skin  between  the  needles  is  thus  nipped,  and  in  about 
an  hour  the  area  of  skin  so  marked  off  will  show  changes  of  color  and 
temperature,  and  will  no  longer  turn  white  on  digital  pressure.  By  this 
method,  w^hich  can  be  carried  out  in  stages  at  intervals  of  about  eight 
days,  the  blood  supply  of  the  prospective  flap  can  be  regulated  so  as  to 
pass  mainly  through  the  part  destined  to  act  as  the  pedicle,  and  ade- 
quate provision  can  be  made  for  the  blood  supply  of  even  a  long  and 
narrow  flap.  Instead  of  the  darning  needle,  a  modification  of'Makkas' 
clamps  for  compressing  the  scalp  before  trephining  may  be  used. 

I  have  found  that  the  surety  of  a  blood  supply  before  transplantation 
of  the  flap  is  very  advantageous,  and  the  principle  deserves  wider 
recognition  than  has  hitherto  been  accorded  it. 

I  usually  wait  for  from  ten  days  to  two  weeks  before  amputating 
the  pedicle  of  a  flap.  Some  have  advised  amputation  as  early  as  the 
fourth  day;  others  insist  that  three  weeks  should  elapse  before  severing 
the  pedicle.  The  circulation  of  the  flap  may  be  tested  before  cutting  the 
pedicle  by  applying  a  stomach  clamp  across  the  pedicle  tight  enough 
to  shut  off  the  circulation,  but  not  sufficiently  tight  to  damage  the 
tissue.  The  amputation  may  be  done  at  once  or  by  making  notches  on 
one  or  both  sides  of  the  pedicle,  thus  gradually  cutting  off  the  circulation 
at  various  intervals.  After  the  pedicle  has  been  cut  through,  the  free 
end  of  the  flap  should  be  fitted  to  its  proper  place  at  once  and,  whenever 
possible,  the  stump  of  the  pedicle  should  be  returned  to  its  original 
bed,  as  in  this  way  a  better  result  can  be  obtained  with  little,  if  any, 
loss  of  tissue. 

Flaps  of  normal  skin  are  often  successfully  shifted  into  the  midst 
of  scar  tissue,  as  in  the  popliteal  and  cubital  spaces,  but  one  should 
make  sure  that  the  circulation  of  these  flaps  is  especially  good. 

Immobilization  of  the  part  is  essential.  The  dressing  next  to  the 
transplanted  area  should  be  soft  and  very  carefully  and  evenly  applied. 
My  own  preference  is  for  the  use  of  compresses  wet  with  normal  salt 
solution  for  the  first  48  hours.  In  shifting  double-pedicled  flaps  on 
the  neck  or  from  the  neck  to  the  chin  or  lip,  it  is  advisable  to  provide 
for  drainage  with  a  small  protective  w^ick  in  each  lower  angle. 

The  flap  should  be  inspected  frequently,  as  the  evacuation  of  a 
collection  of  serum,  the  combating  of  a  slight  infection,  or  the  loosening 
of  tight  stitches  may  change  into  a  success  what  might  otherwise 
prove  a  failure. 

Occasionally  it  may  be  necessary  within  the  first  48  hours  to  shift 


PEDUNCULATED  FLAPS  ^  1 27 

the  flap  back  to  its  original  position,  when  for  one  reason  or  another 
its  death  seems  imminent. 

Skin  flaps  may  be  turned  into  the  mouth  to  take  the  place  o£  de- 
stroyed mucous  membrane.  Flaps  may  also  be  inserted  by  tunneling 
under  normal  tissue.  This  may  be  done  with  the  ordinary  peduncu- 
lated skin  flaps  or  with  island  flaps. 

Double  pedicled  ''gauntlet"  flaps  raised  from  the  chest,  abdominal 
wall,  back,  or  thigh,  are  often  used  for  the  repair  of  lesions  involving 
the  hand  or  fingers.  The  flap  is  raised,  the  part  is  slipped  beneath  it 
and  is  immobilized.  After  the  blood  supply  has  been  assured  the 
pedicles  are  cut,  either  both  at  one  time,  or  separately,  and  the  edges 
of  the  flap  are  sutured  into  position. 

The  transplantation  of  flaps  whose  pedicle  consists  practically  of 
only  the  temporal  artery  and  veins,  was  reported  by  Monks  in  1898. 
He  constructed  a  new  lower-lid  by  using  a  crescen tic-shaped  flap  of 
the  skin  of  the  forehead,  into  which  ran  the  anterior  temporal  artery. 
He  then  dissected  out  the  artery  and  accompanying  veins  and,  after 
tunneling,  passed  the  flap  through  and  sutured  it  in  position,  thus 
leaving  the  vessel  under  the  skin.  Horsley,  in  19 15,  suggested  a  some- 
what similar  procedure  for  repairing  a  cheek  defect,  not  being  aware  of 
]\Ionks'  report.  He  did  not  use  the  tunnel  method,  but  implanted  his 
vessels  in  an  incision  which  was  closed  over  them.  The  principle  was 
the  same,  although  the  size  of  the  flap  and  the  technic  were  difTerent. 

If  by  chance  the  nerve  which  supplies  the  portion  of  the  skin  w^hich 
is  used  as  a  flap  should  pass  through  the  pedicle,  the  sensation  remains 
in  the  flap  until  the  pedicle  is  cut,  but  afterward  for  the  time,  being 
the  sensation  is  cut  ofif.  After  five  or  six  weeks  sensation  begins  to 
return  because  the  nerve  supply  comes  in  from  the  periphery,  as  in 
whole-thickness  skin  grafts.  The  flap  regains  tactile  sensibility  first, 
then  pain,  and  finally  temperature  sense.  If  the  flap  is  large,  the  cen- 
tral portion  may  not  regain  its  sensation  for  a  considerable  time. 

In  my  last  two  rhinoplastic  operations  by  the  Indian  method,  the 
pedicle  contained  the  left  angular  artery,  and  evidently  an  undisturbed 
nerve  supply,  for  when  the  stitches  were  removed  along  the  alie  and 
columna,  both  patients  complained  of  pain  high  up  on  the  forehead. 
This  sensation  was  frequently  tested  and  continued  for  several  weeks, 
until  the  pedicle  was  cut,  a4"ter  which  all  sensation  was  temporarily 
eliminated. 

Grafts    of    all    types   may    become   pigmented,   but   pigmentation 


128  PLASTIC  SURGERY 

seldom  occurs  in  pedunculated  flaps,  and  for  this  reason  they  are  to  be 
preferred  on  the  face  and  other  exposed  positions. 

In  addition  to  the  use  of  the  ordinary  skin  and  subcutaneous  fat 
flap,  pedunculated  flaps  of  other  tissues  may  be  used  in  reconstructive 
surgery. 

Mucous  Membrane.- — Pedunculated  flaps  of  mucous  membrane, 
when  available,  may  be  used  with  satisfaction  for  filling  in  lip  and  cheek 
defects. 

Fat. — Pedunculated  flaps  of  fat  are  often  used  to  fill  defects  in  bone, 
to  raise  depressed  scars,  to  surround  tendons  and  nerves,  and  to  prevent 
adhesions.  It  is  also  used  in  joints,  but  the  combined  fat  and  fascia 
flap  is  superior  in  arthroplastic  operations. 

Muscle. — Pedunculated  flaps  of  muscle  are  used  to  fill  defects  in 
bone,  as  after  mastoid  operations,  and  to  fill  out  depressions,  for  ex- 
ample, those  caused  by  the  destruction  of  the  malar  bone  in  war 
wounds. 

Fascia. — Pedunculated  flaps  of  fascia  are  often  used  with  success  to 
reinforce  weakened  tissue,  for  instance,  in  hernia  operations. 

A  review  of  the  literature  shows  that  during  the  last  hundred  years 
practically  every  portion  of  the  surface  of  the  body  has  been  repaired 
by  means  of  pedunculated  flaps  for  the  relief  of  defects,  either  con- 
genital or  acquired. 

The  use  of  the  pedunculated  flap  of  skin  with  the  required  amount 
of  fat  is  one  of  the  most  dependable  methods  at  our  command  for  the 
repair  of  tissue  defects.  It  is  especially  useful  in  repairing  defects 
opening  into  the  mouth,  nose,  bladder  or  vagina.  No  other  surgical 
procedure  is  so  effective  in  bringing  about  permanent  elastic  healing  in 
areas  exposed  to  constant  trauma,  as  around  joints,  on  the  soles  of  the 
feet,  and  elsewhere. 

A  pedunculated  flap  with  good  circulation  will  live  and  succeed  in 
positions  in  which  free  transplants  are  contraindicated.  The  neglect 
of  this  valuable  surgical  measure  is  quite  general  among  surgeons,  but 
its  many  advantages  should  assure  its  constant  employment  in  suitable 
cases. 

By  the  use  of  pedunculated  flaps  not  only  may  function  be  restored, 
but  also  cosmetic  results  be  obtained  in  many  cases  otherwise  beyond 
the  help  of  surgical  procedures. 

BIBLIOGRAPHY 

Babcock,  W.  W.     "J.  Alumni  Assn.   College  of  Phys.  &  Surg."     Baltimore,  191 2-13, 
XV,  85. 


PEDUNCULATED  FLAPS  1 29 

Beck,  C.     "Surg.,  Gyne.  &  Obst.,"  March,  1918,  259. 
Bull,  W.  T.     "Trans.  Amer.  Surg.  Assn.,"  1895,  xiii,  492. 

C.\MERA,  U.     "Clin.  Chir."     Milano,  1916,  x.xiv,  1224. 

C.^RPtiE,  J.  C.     "Two  Successful  Operations  for  Restoring  a  Lost  Nose."    London,  1816. 

Chavannaz.     Cited  by  Lefevre. 

CiGNOZZi,  O.     "Policlinico."     Rome,  April,  1916,  s.  s..  No.  4. 

Cole,  P.  P.     "Lancet."     London,  Jan.  5,  1918,  11. 

Crawford,  H.     "Med.  Press  &  Circ."    London,  1915,  cl,  588. 

Croft.     "Med.  Chir.  Trans.,"  1889,  Ixxii,  349. 

D.wis,  J.  S.     "Anns.  Surg.,"  March,  1913,  361. 

"Johns  Hopkins  Hospital  Bull.,"  April,  1913,  116. 

Esser.     "New  York  Med.  Jour.,"  Aug.  11,  191 7,  264. 

Finney,  J.  M.  T.     "Trans.  Amer.  Surg.  Assn.,"  1909,  298. 
Franke,  F.     "Deutsche  med.  Wchnschr.,"  Aug.  5,  1915- 

Gersuny,  R.     "Centralbl.  f.  Chir.,"  1887,  xiv,  706. 

V.  Hacker.     "Wiener  klin.  Wchnschr.,"  Jan.  13,  1910,  xxiii,  Nr.  2. 
H.ALSTED,  W.  S.     "Johns  Hopkins  Hospital  Bull.,"  1897,  25. 
Horsley.     "J.  A.  M.  A.,"  Jan.  30,  1915,  408. 

Jacobovici.     "La  Semain  Med.,"  December,  191 1,  613. 

L.AURENT,  O.     "Bull,  de  I'Acad.  de  Med."     Paris,  April  15,  1918,  481. 
Ludington,  N.  a.     "Surg.,  Gyne.  &  Obst.,"  Jan.,  1918,  13. 
Lefevre.     "Arch.  gen.  de  Chir."     Paris,  Feb.,  1913,  No.  2. 
Lund.     Quoted  by  Finney. 

M.\AS.     "Arch.  f.  klin.  Chir.,"  1885,  Bd.  31,  S59- 

"Verhandl.  deutsch.  Gesellschaft.  f.  Chir.,"  14th  Kongress,  1885,  ii,  447. 

"Arch.  f.  klin.  Chir.,"  1886,  Bd.  zi,  323- 
Manchot,  C.  "Die  Hautarterien  des  Menschlichen  Korpers,"  Leipzig,  1889. 
McWiLLiAMS,  C.  A.     "Trans.  N.  Y.  Surg.  Soc.  Anns.  Surg.,"  Nov.,  191 7,  598. 
Monks,  G.     "Boston  Med.  &  Surg.  Jour.,"  Oct.  20,  1898,  385. 
Murphy,  J.  B.     "Surgical  Clin."     Chicago,  1915,  iv,  463. 

"Surgical  Clin."     Chicago,  1915,  iv,  497. 

P.\YR.     "Centralbl.  f.  Chir.,"  Sept.  5,  1908,  1065. 
Perthes,  G.     "Centralbl.  f.  Chir.,"  191 7,  Bd.  44,   641. 
Phillips,  C.  E.     "J.  A.  M.  A.,"  Nov.  15,  1913,  1792. 

ScALONE,  I.     "Policlinico."     Rome,  July  14,  1918,  653. 

Semken,  J.  H.     "Med.  Rec."     New  York,  1914,  652. 

Shrady,  G.  F.     Quoted  by  Sir.  Wm.  MacCormac,  "Birmingham  Med.  Review,"  xiv,  1888, 

241. 
Stone,  J.  S.     "Boston  Med.  &  Surg.  Jour.,"  1905,  clii,  246. 
Strandberg,  J.     "Hygiea."     Stockholm,  Ixxvii,  No.  7. 
Trinkauf,  a.     "Dissertation."     Leipsic,  1913. 
Watts,  S.     "Anns.  Surg.,"  1905,  xli,  118. 
9 


CHAPTER  VII 

THE  TREATMENT  OF  WOUNDS 

GENERAL  CONSIDERATIONS 

It  may  be  thought  by  some  that  a  consideration  of  the  treatment 
of  wounds  is  out  of  place  in  a  work  on  plastic  surgery.  Nevertheless 
if  we  bear  in  mind  the  fact  that  it  is  often  of  vital  importance  to  the 
ultimate  result,  that  either  healing  take  place  before  a  plastic  operation 
can  be  safely  done,  or  that  a  granulating  wound  must  be  brought  into 
a  healthy  condition  before  skin  grafting  can  be  carried  out,  the  necessity 
for  a  full  understanding  of  the  subject  on  the  part  of  the  plastic  surgeon 
will  be  readily  appreciated. 

The  treatment  of  wounds  is  an  unending  source  of  interest,  and  one 
of  the  most  fascinating  subjects  for  study  in  the  entire  field  of  surgery. 
In  the  following  pages  I  shall  not  attempt  to  cover  the  multitudi- 
nous methods  that  have  been  advocated,  but  shall  consider  only  those 
which  I  have  used  and  which  seem  to  be  of  interest  at  this  time. 

The  treatment  of  wounds  is  not  a  simple  matter,  although  until 
the  beginning  of  this  war  little  attention  was  paid  to  wound  treatment 
by  the  ordinary  operating  surgeon,  unless  he  was  especially  interested 
in  some  special  phase  of  the  process.  Dressings  were,  as  a  routine, 
left  to  the  care  of  the  student  dresser,  or  to  the  interne,  even  in  the  most 
extensive  cases.  But  the  vast  numbers  of  wounded  in  this  great  war 
have  again  stimulated  interest  on  the  subject,  and  it  is  now  conceded  that 
in  the  majority  of  surface  wounds  the  good  results  obtained  are  depend- 
ent largely  on  the  skill  with  which  they  are  handled. 

The  main  object  in  the  treatment  of  all  wounds,  whatever  the 
method  used,  is  to  put  them  in  the  most  favorable  condition  for  healing. 

Each  individual  granulating  surface  wound  should  be  studied 
separately  inasmuch  as  no  single  routine  method  of  treatment  has  yet 
been  found  which  is  equally  efficient  in  every  case.  Granulating 
wounds  should  be  dressed  frequently,  and  the  best  results  are  obtained 
when  the  treatment  is  varied. 

I  shall  not  consider  the  histological  changes  which  take  place  in 
the  healing  of  wounds,  as  these  changes  are  familiar  to  every  one.     The 

130 


THE  TREATMENT  OF  WOUNDS  I3I 

efficiency  and  skill  of  a  surgeon  may  be  judged  quite  accurately  by 
observing  him  as  he  does  a  difficult  dressing. 

It  must  be  impressed  on  every  student  and  interne,  and  be  remem- 
bered by  the  more  experienced  surgeon  that  all  dressings  should  be 
done  with  exactly  the  same  consideration  for  the  comfort  of  the  patient, 
and  the  safety  of  the  tissues,  as  the  dresser  would  desire  if  he  himself 
were  the  patient. 

It  is  quite  difficult  to  determine  the  true  value  of  the  various 
methods  of  wound  treatment,  both  on  fresh  wounds  and  on  chronic 
ulcers.  One  surgeon  may  obtain  good  results  in  a  certain  way,  whereas 
another  using  the  same  method,  may  find  the  results  unsatisfactory. 
This  difference  may  be  due  entirely  to  the  careful  handling  of  the  grow- 
ing tissues  in  one  case,  and  to  careless  treatment  in  the  other,  the 
method  itself  actually  having  little  to  do  with  the  results  obtained. 

The  most  satisfactory  way  of  making  a  comparison  of  different 
methods  of  treatment  is  to  have  the  same  surgeon  treat  different 
wounds  on  the  same  patient  by  different  methods.  This,  however, 
is  not  always  possible  to  do.  But  whatever  the  method  of  treatment 
used,  it  is  an  established  fact  that  better  results  are  always  obtained 
by  surgeons  as  they  become  more  experienced  in  the  actual  handling 
of  wounds. 

The  general  condition,  the  surroundings,  and  even  the  mental 
attitude  of  the  patient  must  be  taken  into  consideration,  as  these  are 
important  factors  where  methods  are  to  be  compared.  The  location 
and  the  vascularity  of  the  part,  the  degree  of  trauma  of  the  soft  parts 
and  the  extent  and  kind  of  infection,  must  also  be  considered. 

Often  the  tissues  around  the  wounds  are  more  or  less  infiltrated  with 
scar,  and  this  is  a  most  important  factor,  as  it  makes  the  problem  of 
wound  healing  and  operative  procedure,  much  more  difficult. 

Recent  Wounds 

It  is  imperative  to  inject  a  prophylactic  dose  of  500  units  of  tetanus 
antitoxin  as  soon  as  possible  after  the  wound  is  received,  and  a  similar 
dose  after  ten  days,  unless  the  wound  is  very  slight. 

In  time  of  peace  the  plastic  surgeon  is  seldom  called  upon  to  treat 
recent  wounds.  In  time  of  war,  however,  such  wounds  of  the  face  are 
frequently  referred  to  him,  and  these  may  be  divided  into  two  general 
groups. 

Group  i. — Cases  in  wJiich  there  is  injury  to  the  soft  parts  alone. 


132  PLASTIC  SURGERY 

This  group  may  be  subdivided  in  (a)  those  in  which  the  tissues  are  cut 
or  lacerated,  but  where  there  is  a  possibiHty  of  replacing  and  suturing 
them,  in  more  or  less  normal  position,  {h)  those  in  which  there  has 
been  extensive  destruction  of  the  soft  parts  with  no  possibility  of  im- 
mediate closure. 

Group  2. — Cases  in  which  there  is  injury  or  destruction  of  the  hone. 
The  bone  injury  may  be  associated  with  conditions  belonging  to  either 
of  the  subdivisions  spoken  of  in  group  i. 

Group  i,  a. — When  the  soft  parts  may  he  approximated,  it  is  impor- 
tant to  suture  the  tissues  as  soon  as  possible  after  disinfection  with 
ether  (preferably)  or  iodin,  and  if  necessary  excision  of  devitalized 
tissues. 

Valadier  and  Whale  say  that  "however  dirty  the  wound,  it  should  be 
closed  within  a  few  days,  and  long  before  it  is  thoroughly  clean."  Per- 
fect asepsis  is  unattainable,  inasmuch  as  most  of  these  wounds  open 
into  the  mouth. 

It  is  best  to  suture  these  wounds  in  layers;  the  mucous  membrane 
separately,  if  possible,  with  catgut,  then  with  buried  sutures  of  catgut 
for  the  muscle  and  fascia  layer,  and  with  silkworm-gut  or  horsehair  for 
the  skin.  The  deep  sutures  may  occasionally  enter  the  mouth  if 
necessary,  and  may  even  be  tied  there.  All  of  these  sutures  should 
be  inserted  at  a  considerable  distance  from  the  wound  margin.  To  rein- 
force these  layers  wide  tension  sutures  of  silkworm  gut  may  be  used, 
tied  over  lead  plates  or  vulcanite  buttons. 

When  laceration  is  present,  it  is  unwise  to  attempt  to  bring  the 
parts  into  perfect  approximation,  because  the  tension  on  the  sutures 
may  hasten  a  break  down.  Infection  often  occurs  in  these  wounds 
and  may  cause  the  superficial  sutures  to  break  down  within  a  few  days, 
but  usually  they  hold  until  the  deeper  layers  have  granulated. 

Group  i,  h. — When  there  is  extensive  destruction  of  the  soft  parts 
often  but  Httle  can  be  gained  by  drawing  the  edges  toward  each  other 
with  sutures,  nevertheless,  properly  placed  tension  sutures  may  aid 
in  preventing  contracture.  Every  particle  of  tissue  not  obviously  dead 
should  be  preserved,  more  especially  if  it  be  mucous  membrane.  When 
the  destruction  of  the  upper  or  lower  lip  or  cheeks  has  been  sufficient 
to  prevent  approximation  the  mucous  membrane  should  be  sutured  to 
the  skin,  and  the  plastic  operations  for  permanent  closure  be  deferred 
until  later. 

The  object  of  these  procedures  is  to  aid  in  the  prompt  healing  of 
the   wound,   and   to  prevent  unnecessary  contracture.     Those  parts 


THE  TREATMENT  OF  WOUNDS  I33 

which  are  difficult  to  reconstruct  (such  as  the  columna  and  ala  of  the 
nose)  should  be  most  carefully  preserved. 

Before  anything  further  can  be  accomplished  with  safety,  it  is  neces- 
sary to  overcome  infection,  and  allow  healing  to  take  place.  Then,  by 
the  selected  plastic,  or  series  of  plastic  operations,  the  defect  may  be 
closed  with  flaps  of  living  tissue  either  from  adjacent  or  from  distant 
parts,  as  seems  most  advisable. 

Group  2. — When  there  has  been  fracture  or  destruction  of  the  hone^ 
hut  when  closure  of  the  soft  parts  is  still  possible,  the  ideal  method  of  treat- 
ment is  the  application  of  a  temporary  prosthesis,  in  order  to  immobilize 
the  bone  fragments,  after  which  the  soft  parts  should  be  sutured  over  it 
as  described  for  Group  i.  A  permanent  supporting  structure  may 
then  be  made,  or,  after  the  wound  is  in  condition,  bone  or  cartilage  may 
be  transplanted  to  fill  the  defect. 

In  cases  in  which  destruction  of  the  soft  parts  is  so  extensive  as  to 
prevent  closure,  and  there  is  bone  destruction  also,  it  is  advisable  to 
insert  the  proper  dental  appliance  at  once,  to  keep  the  remaining  bone 
fragments  in  position,  and  to  prevent  unnecessary  shrinkage  of  the  soft 
parts.  After  this  the  treatment  is  that  of  Group  i.  After  healing  of 
the  soft  parts  has  taken  place,  a  plastic  operation  to  close  the  defect 
should  be  done,  with  the  prosthetic  appliance  in  position.  Subse- 
quently a  bone  or  cartilage  graft  may  be  inserted  in  the  bone  defects, 
unless  it  appears  wiser  to  depend  on  the  permanent  artificial  support. 
Earlier  in  the  war,  when  this  was  not  done,  it  was  found  that  the  splints 
could  not  be  applied  later,  on  account  of  contraction  of  the  soft  parts. 
In  many  of  these  cases  the  soft  parts  had  to  be  reopened  before  the 
necessary  apparatus  could  be  applied,  but  even  then  the  obliteration 
of  the  buccal  sulcus  and  contraction  of  scar  tissue  limited  the  function 
of  the  jaws  permanently. 

Wounds  of  the  face  cannot  be  treated  by  complete  excision  as  readily 
as  those  in  other  portions  of  the  body.  Nevertheless,  all  tissue  that  is 
without  vitality  should  be  excised.  All  foreign  bodies  and  unattached 
splinters  of  bone  should  be  removed.  Hemorrhage  should  be  checked. 
Every  particle  of  bone,  however  small,  which  is  still  attached  to  its  perio- 
steum should  be  conserved,  and  as  much  of  the  mucous  membrane  as 
possible.     All  teeth  should  be  preserved  for  supporting  purposes. 

Wounds  leading  into  the  mouth  or  nose  are  especially  difficult  to 
keep  clean,  and  in  these  cases  free  drainage  should  be  provided  through 
the  floor  of  the  mouth,  in  the  mid-submaxillary  region,  if  openings  in 
dependent  portions  are  lacking. 


134  PLASTIC  SURGERY 

Frequent  irrigations  with  Dakin's  solution,  weak  peroxide,  normal 
salt  or  boric  solutions,  Wright's  solution,  or  permanganate  of  potash, 
are  important.  Mouth  washes  should  be  used,  and  every  effort  should 
be  made  to  overcome  infection  and  promote  healing.  Dichloramine-T 
applied  on  swabs,  or  as  a  spray,  is  often  useful. 

Much  has  been  done  to  overcome  infection,  and  to  promote  primary 
healing  in  war  wounds,  but  probably  nothing  has  as  yet  given  the 
rapid  results,  in  selected  cases,  that  have  followed  debridement  or  exci- 
sion of  the  wounded  area,  as  used  by  the  surgeons  at  the  Front. 

I  shall  consider  this  method  only  in  so  far  as  it  may  apply  to  plastic 
work. 

A.  Depage  (one  of  the  earliest  and  most  enthusiastic  advocates  of 
the  method)  has  covered  the  ground  thoroughly,  and  the  following 
remarks  on  debridement  are  based  mainly  on  his  ideas. 

Some  surgeons  have  advised  the  excision  of  the  wounded  area  en  bloc, 
but  this  is  only  possible  in  comparatively  short  superficial  tracts  and 
not  in  the  long  deep  tortuous  wounds  so  often  found. 

Before  proceeding  to  a  debridement,  the  surgeon  should  acquaint 
himself,  as  exactly  as  possible,  with  the  situation  of  the  tract  in  its 
relation  to  the  different  anatomical  structures.  The  direction  of  the 
incisions  should  vary  with  the  region  implicated  and  with  the  nature 
of  the  wound. 

In  a  superficial  wound  the  two  orifices  should  be  excised,  and  the  bridge 
of  interposed  tissue  divided,  transforming  the  tract  into  a  furrow.  After 
this  the  sides  or  floor  of  the  furrow  are  completely  excised.  Should  the 
wound  be  deep,  every  portion  of  it  should  be  carefully  explored,  and  all 
foreign  bodies  and  devitalized  tissue  removed.  Muscles  should  be 
divided  transversely,  when  it  is  necessary  to  give  proper  exposure. 

After  debridement  the  continuity  of  the  muscles  should  be  imme- 
diately reestablished  by  means  of  mattress  sutures  of  catgut,  but  if  any 
doubt  exists  as  to  the  condition  of  the  wound,  the  muscle  suture  may  be 
delayed  for  two  or  three  days.  Nerves  and  vessels  should  be  preserved 
when  muscles  are  divided  transversely. 

The  Suturing  of  Wounds. — The  suturing  of  the  wound  may  be 
done  immediately  after  debridement — the  primary  suture. 

It  may  be  done  during  the  first  five  or  six  days — the  delayed  primary 
suture.  For  this  as  in  the  primary  suture,  the  edges  are  simply  brought 
together. 

The  suturing  may  be  performed  after  chemical  sterilization  of  the 
wound  by  Dakin's  solution — the  secondary  suture. 


THE    TREATMENT    OF    WOUNDS  135 

The  time  for  making  the  delayed  or  retarded  primary  suture  is  deter- 
mined by  bacteriological  control.  At  the  first  dressing  from  12  to  24 
hours  after  the  debridement,  a  smear  and  culture  are  taken.  At  the 
second  dressing,  from  36  to  48  hours  after  the  debridement,  the  process 
is  repeated.  If  the  first  culture  does  not  show  any  streptococci,  and 
the  bacterial  count  in  the  last  smear  does  not  exceed  i  for  every  2 
fields,  the  wound  is  sutured. 

The  retarded  primary  suture  should  not  be  employed  after 
the  second  dressing,  if  the  bacterial  count  shows  an  increase,  even  if  no 
streptococci  have  been  demonstrated  in  the  culture.  The  use  of  the 
retarded  primary  suture  rarely  brings  about  failure  with  serious  compli- 
cations, but  it  involves  the  inconvenience  of  two  operations. 

The  secondary  suture  is  reserved  for  wounds  which  cannot  be 
sutured  during  the  first  few  days,  owing  to  a  too  widely  injured  area  or 
to  a  threatened  infection.  It  is  a  safe,  but  slow  method,  and  never  gives 
as  good  a  functional  result  as  the  primary  or  the  delayed  primary 
sutures.  It  should  be  practised  regularly  when  the  bacterial  control 
remains  below  i  for  every  4  fields,  and  after  two  successive  cultures 
have  showed  no  streptococci. 

Dressings  for  Sutured  Wounds 

In  many  instances  a  carefully  sutured  wound  may  be  exposed  to  the 
air  either  without  dressings,  after  being  painted  with  tincture  of  iodin, 
or  after  being  dusted  with  calomel,  subiodid  of  bismuth  or  some  other 
powder. 

Silver  foil,  first  suggested  by  Halsted,  has  never  been  improved  upon 
as  a  dressing  for  clean  sutured  wounds.  It  has  a  slight  antiseptic  action. 
In  wounds  around  the  mouth  and  nose  the  apphcation  over  the  suture 
line  of  compound  tincture  of  benzoin,  which  has  been  evaporated 
to  a  thin  syrupy  consistence  (suggestion  by  E.  H.  Ochsner)  has 
proved  very  satisfactory,  and  by  its  use  many  infections  may  be 
avoided.  Gauze  wet  with  normal  salt  solution,  or  with  a  watery  solu- 
tion of  iodin  (1-500)  may  be  used  next  to  the  wound,  and  allowed  to 
dry  out. 

When  wet  dressings  are  indicated  (as  in  the  transplantation  of  flaps, 
or  where  infection  is  feared),  in  my  own  experience  gauze  wet  with  a 
saturated  boric-acid  solution  or  normal  salt  solution,  and  kept  wet  for 
varying  periods,  has  proved  satisfactory. 


136 


PLASTIC  SURGERY 


Granulating  Wounds 

In  time  of  peace  wounds  which  are  referred  to  the  plastic  surgeon  are, 
as  a  rule,  of  two  kinds:  (i)  Extensive  wounds  due  to  hums  or  trauma, 
involving  the  destruction  of  the  entire  thickness  of  the  skin  and  often 
some  of  the  underlying  soft  parts,  whose  size  or  position  necessitates 
skin  grafting  or  plastic  operation,  in  order  to  ensure  a  rapid  stable 
healing. 

(2)  Intractable  wounds  or  ulcers,  which  have  resisted  all  the  usual 
methods  of  treatment. 

Many  of  the  wounds  in  Group  i  are  due  to  burns,  and  for  the  sake  of 
clarity  I  shall  classify  burns  as  follows: 


Fig.  114. — Second  degree  burn  of  the  forearm.  Duration  3  days. — The  extent  of  the 
large  blister  which  has  been  opened  in  several  places  under  aseptic  precautions  is  shown  by 
the  white  area.  No  infection  occurred  and  the  blistered  skin  was  not  removed.  A  portion 
of  it  adhered  to  the  wound  much  like  a  thin  graft,  and  a  portion  dried  and  was  removed. 


First  Degree  Burns,  where  the  skin  is  reddened. 

Second  Degree  Burns,  where  the  skin  is  blistered. 

Third  Degree  Burns,  where  there  is  destruction  of  the  entire 
thickness  of  the  skin,  or  of  the  skin  and  deeper  tissues. 

Shell  Gas,  "Mustard  Gas"  Burns  (Dichlorethylsulphide) . — 
Burns  caused  by  this  gas  were  practically  unknown  before  the  introduc- 
tion of  this  barbarous  method  of  warfare  by  the  Germans.  They  may 
occur  during  its  manufacture,  but  much  more  commonly  in  gas  attacks. 
The  majority  of  these  burns  are  superficial,  but  occasionally  there  is 
destruction  of  the  skin  and  the  underlying  tissues  to  various  depths, 
producing  a  tendency  to  great  sluggishness  and  successive  layers  of 
sloughing. 


THE    TREATMENT    OF    WOUNDS 


137 


The  insidiousness  of  the  gas  and  the  difficulty  in  handling  the 
burns  without  causing  further  damage  to  both  attendant  and  patient 
from  the  contents  of  the  blisters  makes  the  early  care  quite  tr>^ng. 

It  is  hoped  that  this  type  of  burn  will  hereafter  be  practically  ehmi- 
nated,  and  that  the  manufacture  and  use  of  "mustard  gas"  will  now 
cease  for  ever. 

Recent  burns  seldom  come  under  the  care  of  the  plastic  surgeon. 
These  cases  are  usually  referred  to  him  when  they  have  become  granu- 
lating wounds,  therefore  I  shall  consider  burns  only  from  that  standpoint. 


Fig.  115. — A  crush  burn  of  the  palm  of  the  hand  and  lingers.  Duration  three  weeks. 
The  deep  destruction  of  tissue  would  eliminate  the  successful  use  of  a  thin  graft  in  this 
case,  except  as  a  preliminary  measure.  The  only  chance  of  restoring  function  is  to  cover 
the  palm  and  fingers  with  pedunculated  flaps  of  skin  and  fat. 


The  Care  of  the  Skin  Surrounding  a  Wound 


The  care  of  the  skin  surrounding  a  wound  is  important,  as  its  healthy 
condition  means  much  in  the  healing  process.  If  the  skin  is  infected,  or 
irritated,  it  is  difficult  to  put  the  wound  in  a  healthy  condition,  and  in 
addition  the  dressings  are  seldom  comfortable. 

Irritation  may  be  caused  by  wound  secretions,  by  the  drugs  applied, 
or  by  the  constant  use  of  adhesive  plaster  in  the  same  places.  Ether, 
benzine,  or  gasoline  are  probably  the  best  solutions  for  cleansing  the  skin 
immediately  surrounding  the  wound,  as  they  remove  secretions  and 


138  PLASTIC  SURGERY 

oily  substances  and  do  not  irritate.  The  skin  surrounding  the  entire 
part  should  be  sponged  with  alcohol  and  gently  massaged,  if  possible, 
everyday. 

In  ulcers,  or  in  fact  in  any  wound,  in  which  the  secretions  or  type 
of  dressings  are  liable  to  cause  irritation,  I  anoint  the  skin  for  several 
inches  around  the  wound  with  some  bland  ointment,  preferably  zinc 
oxid  in  benzoinated  lard  (U.S. P.).  Lanolin  and  liquid  paraffin  may 
be  successfully  used  for  the  same  purpose. 

The  use  of  a  mixture  called  "Steroline,"  a  sherry-colored  fluid,  with 
a  pleasant  odor,  having  the  formula.  Balsam  of  Peru  4.C.C.;  castor  oil 
and  Venetian  turpentine  of  each  2.c.c.;  alcohol  (95  per  cent)  100.  c.c, 
was  first  reported  by  R.  Frank.  It  is  intended  to  be  used  as  an  emer- 
gency method  of  cleaning  the  patient  or  the  hands  of  the  surgeon.  It 
leaves  a  very  thin,  shiny,  dry  coating  on  the  skin,  which  sheds  water. 
I  have  used  Steroline  in  the  out-patient  department  for  several  years, 
both  to  protect  the  skin  around  wounds,  and  to  protect  my  hands,  and 
have  found  that  it  is  non-irritating  and  leaves  the  skin  soft.  I  have 
not  felt  justified  in  using  it  in  hospital  practice  instead  of  rubber  gloves, 
and  the  standard  methods  of  cleaning  the  skin.  Steroline  is  also  an 
excellent  dressing  for  first-degree  burns,  it  relieves  the  pain  and  reduces 
inflammation. 

The  Avoidance  of  Pain  During  Dressing 

Pain  during  dressings  is,  of  course,  unavoidable  in  some  instances, 
but  with  the  various  means  at  our  command  much  can  be  done  to  reduce 
it  to  a  minimum.  Every  care  should  be  taken  to  avoid  dressings  which 
stick  closely  to  the  granulations,  as  their  removal  necessarily  causes 
pain  and,  furthermore,  does  great  damage  to  the  granulation  tissue, 
and  also  to  the  epithelium  growing  in  from  the  edges. 

It  is  a  good  rule  never  to  put  loose-meshed  dressing  gauze  immedi- 
ately in  contact  with  a  surface  wound,  unless  it  is  either  smeared  with 
some  ointment,  soaked  in  oil,  liquid  parafhn,  or  in  melted  ointments,  or 
is  kept  constantly  wet.  Very  active  wound  secretion  will  also  prevent 
sticking.  It  is  obvious,  also,  that  raw  cotton  should  not  be  placed  on 
an  unhealed  surface. 

Should  the  granulations  grow  into  the  mesh  of  the  gauze,  or  the 
dressing  become  adherent,  it  is  advisable  to  apply  a  liberal  amount  of 
sterile  vaselin  over  the  gauze  next  to  the  wound,  and  finish  the  dressing 
24  hours  later.     During  this  time  the  vasehn  will  soak  into  the  gauze 


THE    TREATMENT    OF    WOUNDS  1 39 

over  the  wound,  and  it  will  be  found  that  the  dressing  may  then  be 
removed  without  pain  or  bleeding.  The  same  purpose  may  be  accom- 
plished more  rapidly  by  saturating  the  gauze  with  sterile  oil  (cotton- 
seed or  olive  oil)  or  with  liquid  paraffin,  and  then  by  Ufting  up  the  edges 
and  dropping  in  more  oil  the  gauze  can  be  removed  without  difficulty. 

Peroxid  of  hydrogen  is  also  useful  for  loosening  gauze,  but  my 
preference  is  for  the  oil. 

Anesthesia  in  Painful  Dressings. — I  have  seen  it  necessary,  in 
certain  very  painful  dressings,  to  use  general  anesthesia  (usually  nitrous 
oxid  and  oxygen),  but  this  is  rarely  necessary  in  civil  practice. 

Hirschman  says  that  in  some  hospitals  at  the  front,  in  dressing  pain- 
ful wounds  when  anesthesia  is  required,  it  is  safely  produced  by  the 
following  mixture:  Ethyl  chlorid  S-c.c;  chloroform  i.c.c;  ether  24.C.C. 

He  describes  its  use  as  follows:  A  piece  of  flannel  cloth  is  saturated 
with  the  entire  mixture,  and  is  placed  over  the  patient's  face.  This 
is  covered  with  another  piece  of  flannel,  and  this  in  turn  with  oiled  silk, 
containing  a  small  opening  over  the  nostrils.  The  whole  is  tied  around 
the  patient's  face,  with  a  piece  of  tape  or  rubber  tubing.  The  anes- 
thesia produced  will  last  for  10  minutes  and  the  dressing  can  be  started 
on  the  second  breath.  This  anesthesia  is  apparently  devoid  of  danger 
of  any  sort,  and  is  welcomed  by  the  patient.  Dineen  describes  a  similar 
method  with  the  following  mixture:  chloroform  2.c.c.;  ether  18.  c.c; 
ethyl  chloride  10.  c.c. 

Method  of  Sponging  a  Granulating  Wound 

After  the  dressing  is  off,  the  wound  should  never  be  rubbed  with 
pledgets  of  gauze  or  sponges,  as  pain  is  caused  and  much  damage  may 
be  done  to  both  the  granulation  tissue  and  to  the  growing  epithelium. 
The  pledgets  should  be  pressed  down  gently  on  the  surface,  and  it  will 
be  found  that  the  secretions  can  be  removed  as  thoroughly  by  this 
method  as  by  wiping  or  rubbing.  The  surrounding  skin  may  be  rubbed 
vigorously,  but  it  is  needless  to  say  that  no  sponge  or  pledget  with  which 
the  skin  has  been  rubbed  should  be  applied  to  the  wound. 

The  Protection  of  Granulations 

Paraffin  Mesh. — Various  methods  have  been  devised  to  prevent 
dressings  from  sticking  to  granulating  wounds.  Linen,  chiffon  silk, 
paper  soaked  in  oil  or  spread  with  ointments,  were  ffist  used.  Later 
oiled  silk  was  devised  by  Lister,  and  subsequently  a  thin  gutta-percha 


I40  PLASTIC  SURGERY 

"protective"  was  devised  by  Dr.  W.  S.  Halsted,  the  latter  now  being 
the  standard  for  surgical  use.^  Waxed  or  paraffin  paper  (either  plain 
or  perforated)  has  been  used  for  many  years  for  the  same  purpose,  but 
is  unsatisfactory,  as  it  tears  so  easily.  The  fabrics  or  protective,  if 
used  next  to  the  wound,  should  be  perforated,  or  V-shaped  slits  be  cut, 
to  allow  the  escape  of  secretions.     All  these  methods  are  efficient. 

It  has  been  found  that  the  use  of  some  meshed  material  (such  as 
mosquito-netting,  or  material  with  larger  openings),  which  is  impreg- 
nated with  paraffin  or  gutta-percha,  will  prevent  sticking.  For  ordinary 
purposes  I  prefer  the  mesh  with  openings  i.  cm.  (%  inch)  in  diameter, 
impregnated  with  rubber  as  previously  described.  This  mesh  can 
also  be  impregnated  with  paraffin. 

A  number  of  methods  of  preparing  mosquito-netting  by  impreg- 
nating it  with  paraffin  have  been  described.  The  following  method  is 
simple  and  satisfactory. 

Cut  the  mesh  into  the  desired  sizes.  Melt  the  paraffin  (Carrel's 
mixture,  Ambrine,  Stanohnd  wax,  or  any  of  the  new  mixtures)  over 
a  water  bath.  Saturate  the  mesh  with  the  melted  paraffin,  remove  the 
mesh  from  the  paraffin,  and  wrap  each  piece  (or  as  many  as  may  be 
desired)  in  waxed  paper,  and  then  in  a  double  muslin  cover.  Sterilize 
with  the  other  dressings.  The  sterilization  will  remove  the  ffims  of 
paraffin  from  the  openings  in  the  mesh,  and  will  leave  sufficient  in  the 
mesh  itself  to  prevent  sticking. 

The  paraffin  mesh  is  most  useful  on  any  granulating  surface,  and 
will  prevent  injury  to  the  granulations  and  to  the  growing  epithelial 
edges,  when  the  dressings  are  changed. 

For  impregnating  the  mesh  Dodd  used  a  mixture  of  pure  paraffin 
and  petrolatum,  each  2  parts,  with  i  part  of  stearin.  H.  E.  Fisher 
prepared  a  non-adherent  gauze  by  saturating  it  with  a  mixture  of  paraf- 
fin, 8  parts,  petrolatum  or  lanolin  2  parts.  I  have  used  for  years  gauze 
saturated  with  liquid  petrolatum  either  plain  or  with  iodin,  1-300  (iodin, 
i.gm.;  liquid  petrolatum  300.  c.c.)  as  a  non-adherent  dressing,  and  also 
gauze  saturated  with  sterile  castor  oil,  for  the  same  purpose,  and  find 
them  very  useful. 

1  On  April  ii,  1912,  Dr.  Halsted  in  his  clinic  said,  that  in  the  early  eighties  ('80  or  '83), 
when  searching  for  some  thin,  reasonable  priced,  oiled  cotton  material  to  take  the  place  of 
Lister's  green  oiled  silk  for  dressing  wounds,  he  came  across  a  thick  gutta-percha  tissue, 
used  at  that  time  as  rubber  sheeting  is  now  used,  and  was  told  by  the  manufacturers  that 
he  could  have  this  made  as  thin  as  desired.  He  experimented  with  many  different  thick- 
nesses untU  finally  the  desired  degree  was  obtained,  and  from  this  came  the  protective^of 
the  present  day. 


THE    TREATMENT    OF    WOUNDS  I4I 

I  have  also  used  perforated  sheets  of  thin  celluloid,  which  has  the 
advantage  of  being  transparent,  and  can  be  obtained  in  any  size  desired. 
E.  O.  N.  Kaire  calls  attention  to  the  use  of  sheet  mica  as  a  protective 
non-adherent,  non-irritating  dressing,  which  is  transparent,  and  can 
be  sterilized  by  dry  heat,  but  only  comparatively  small  sheets  can  be 
obtained. 

Exuberant  Granulations 

Exuberant  granulation  tissue  is  sometimes  difficult  to  deal  with, 
especially  if  the  patient  is  in  bad  condition  and  the  wound  is  painful. 
The  best  procedure,  and  one  which  causes  surprisingly  little  pain,  is 
to  trim  the  granulations  off  to  the  level  of  the  skin  with  curved  scissors. 
The  raw  surface  should  then  be  washed  with  normal  salt  solution  and 
dressed  as  desired. 

The  granulations  after  being  dried  may  be  cauterized  with  silver 
nitrate  stick,  or  with  the  saturated  solution.  Compresses  of  iodoform 
gauze  wet  with  glycerin  are  useful  in  reducing  granulations.  Exposure 
to  the  sun  or  electric  light,  is  an  efficient  method.  Granulations  may 
also  be  reduced  by  the  use  of  Dakin's  solution,  or  of  Dichloramine-T. 
When  Dakin's  solution  is  used  granulations  never  become  exuberant. 

The  Chlorin  Antiseptics 

In  order  to  prepare  a  wound  for  secondary  suture,  or  to  put  it  in 
condition  for  skin  grafting,  or  to  bring  about  the  maximal  speed  in 
unaided  cicatrization,  some  method  must  be  used  which  will  disinfect 
the  wound  and  bring  down  the  bacterial  count. ^ 

The  rehabilitation  of  the  chlorin  germicides  by  Dakin,  and  the 
evolution  of  the  elaborate  technic  necessary  for  the  use  of  the  hypochlo- 
rite solution  by  Carrel,  has  done  much  to  solve  this  problem. 

Early  in  the  war  opinions  as  to  the  possibility  of  chemical  sterili- 
zation of  an  infected  wound  were  divided.     Sir  Almroth  Wright  held 

^  My  attention  was  first  called  to  the  value  of  Labarraque's  solution  (Liquor  sodae 
chlorinata)  many  years  ago  by  Col.  Wm.  B.  Davis,  M.  C,  U.  S.  Army.  I  have  often  used 
it  since  in  the  treatment  of  sluggish  and  infected  ulcers  in  strengths  of  1-8  or  i-io  in  water, 
for  saturating  compresses  which  should  be  changed  every  two  hours.  My  results  have 
been  excellent.  It  is  necessary  to  protect  the  surrounding  skin  from  irritation  with  vase- 
lin  or  zinc  ointment.  Labarraque's  solution  (the  original  chlorin  antiseptic)  was  studied 
by  Dakin  and  Lorraine  Smith,  who  found  that  the  irritation  of  the  skin  was  due  to  the 
alkalinity  of  the  solution.  They  were  able  to  neutralize  this  by  the  addition  of  certain 
salts  and  thus  to  reduce  the  irritating  effect  of  the  solution.  It  was  from  this  that  Dakin 
developed  the  solution  which  now  bears  his  name  and  is  in  such  common  use. 


142 


PLASTIC  SURGERY 


that  this  method  was  impracticable  without  injury  to  the  tissues, 
and  thought  that  the  best  results  in  treating  infected  wounds  could 
be  obtained  from  the  use  of  hypertonic  salt  solutions  of  varying 
strength.^ 

Dakin's  Solution. — It  has  been  proved  beyond  question  that  chem- 
ical sterilization  of  infected  wounds  is  practicable,  and  Henry  D.  Dakin 
found  that  a  solution  of  hypochlorite  of  soda  (0.48  per  cent),  which  has 
been  neutralized  with  boric  acid  and  which  remained  nearly  neutral 
under  all  conditions,  would  destrqy  bacteria  and  neutralize  the  toxins 
without  harming  the  tissues.^ 

In  order  to  maintain  the  needful  strength  of  the  solution,  which 
lessens  rapidly  with  the  dilution  by  the  wound  secretions  and  by  the 
combination -^  of  the  hypochlorite  with  the  proteins,  it  is  necessary  to 


I  2 

Pig.  116. — Arrangement  of  Carrel's  tube  for  the  instillation  of  Dakin's  solution  on  a 
horizontal  wound.  (Carrell  and  Dehelly.) — i.  The  wrong  method  of  placing  the  instilla- 
tion tube.  The  tube  is  on  the  surface  of  the  compress.  2.  The  right  method  of  placing 
the  tube.      The  tube  is  in  contact  with  the  wound  and  covered  with  the  compress. 


keep  it  constantly  renewed.  This  is  best  accomplished  by  intermittent 
instillation. 

It  has  been  found  that  the  most  practical  method  of  application 
is  to  allow  small  rubber  tubes  from  30.  to  40.  cm.  (12  to  16  inches)  long, 
perforated  with  minute  holes  from  0.05  to  o.i  cm.  (about  }io  to  ^i^ 
inch)  to  lie  on  the  tissues.  The  disposal  of  these  tubes  varies  with  the 
shape  and  size  of  the  wound,  but  they  should  be  so  placed  that  the 
solution  will  be  brought  in  contact  with  every  part  of  the  surface. 
Tubes  having  the  perforated  portions  covered  with  turkish  toweling 
are  best  adapted  for  surface  wounds  without  much  discharge.  The 
instillation  may  be  made  by  means  of  a  syringe,  or  of  a  reservoir  with  a 
pinch-cock,  the  latter  being  the  instrument  of  choice  (Figs.  116-118). 

As  soon  as  the  tubes  are  in  position  and  are  secured  by  strips  of 

^  Wright's  Solution. — Sodium  chlorid  4  or  5  per  cent  and  sodium  citrate  i  per  cent, 
in  water.  , 

2  For  a  full  consideration  of  the  elaborate  technic  developed  by  Carrel  in  using  Dakin's 
solution,  and  the  preparation  of  this  solution,  the  reader  is  referred  to  Child's  translation 
of  Carrel  and  Dehelly's  "The  Treatrrtent  of  Infected  Wounds,"  and  Dakin  and  Dunham's' 
"Handbook  of  Antiseptics." 


THE    TREATMENT    OF    WOUNDS 


143 


Sterile  adhesive  plaster,  the  surrounding  skin  and  dependent  portions 
likely  to  become  wet  are  protected  from  erosion  or  irritation  by  squares 
of  gauze  (8.  or  10.  cm.  (3I5  or  4  inches)  which  have  been  sterilized  in 
vaselin  or  in  a  mixture  of  zinc  oxid  100  parts,  vaselin  400  parts,  and 
parawax,  5  parts  (Rockefeller  War  Demonstration  Hospital).  Com- 
presses soaked  in  Dakin's  solution  are  then  applied  over  the  tubes, 


Fig.   117.  Fig.   iiS. 

Fig.  117. — Arrangement  of  Carrel's  tubes  for  the  instillation  of  Dakin's  solution  on  a 
wound  -with  surface  inclined.  (Carrel  and  Dehelly.) — i.  Tubes  placed  the  wrong  way  along 
the  lower  border  of  the  wound.  2.  Tubes  placed  the  right  way  along  the  upper  border  of 
the  wound. 

Fig.  118. — Method  of  instilling  Dakin's  solution  with  a  circular  tube  on  a  surface 
wound. — {Carrel  and  Dehelly.) 

over  which  is  laid  as  an  outside  protection  a  cotton  pad,  the  absorbent 
portion  being  next  to  the  wound. 

ImmobiHzation  is  imperative.  The  dressing  should  be  changed 
every  24  hours.  From  10.  to  20.  cm.  (4  to  8  inches)  of  the  unperforated 
portions  of  the  rubber  tubes  extend  from  the  dressings,  and  their  ends 
are  connected  with  the  reservoir.  The  pinch-cock  is  opened  for  a  few 
seconds  every  two  hours,  and  from  20.  to  100.  c.c.  of  the  hypochlor- 
ite solution  are  allowed  to  flow  over  the  wound.  The  height  of  the 
reservoir  is  from  40.  to  100.  cm.  (16  to  40  inches)  above  the  wound, 
depending  on  the  pressure  desired. 


144  PLASTIC  SURGERY 

The  instillation  continues  day  and  night  until  all  bacteria  have  dis- 
appeared from  smears.  As  long  as  a  few  colonies  remain,  no  alteration 
should  be  made  in  the  quantity  or  frequency  of  the  instillation. 

This  brief  outline  of  the  technic  will  give  some  idea  of  Carrel's 
method.  No  surgeon  should  attempt  to  use  it  without  very  careful 
study  of  Carrel's  instructions,  or  better  still,  after  a  course  in  the  method 
such  as  was  given  in  the  Rockefeller  War  Demonstration  Hospital  to 
the  officers  of  the  Medical  Corps. 

In  general,  from  3  to  lo  days  are  needed  for  the  steriUzation  of  a 
wound,  but  when  it  has  already  been  suppurating  before  the  beginning 
of  the  treatment,  a  much  longer  time  may  be  required.  Bacterio- 
logical examination  alone  should  indicate  when  the  instillations  may 
be  discontinued. 

Wounds,  although  clinically  identical  in  appearance,  may  show 
marked  differences  in  the  bacterial  count.  Five  or  six  bacteria  to  a 
field  can  retard  the  rapidity  of  cicatrization  by  nearly  one-half,  as  com- 
pared with  the  cicatrization  of  a  similar  but  sterile  wound.  It  is  im- 
possible to  tell  by  the  appearance  of  a  wound  whether  it  is  sterile, 
hence,  a  knowledge  of  the  bacteriological  conditions  is  imperative. 

Surgeons  who  have  used  Dakin's  solution,  while  practising  the  care- 
ful observation  of  the  Carrel  technic,  are  almost  unanimous  in  saying 
that  devitalized  tissue  is  dissolved,  that  infection  can  be  controlled 
by  it  more  promptly  than  by  other  methods,  and  that  the  bacterial 
count  shows  immediate  and  constant  diminution. 

The  poor  results  reported  have  been  probably  due  to  the  omis- 
sion of  some  important  point  in  the  technic,  since  absolute  ad- 
herence to  every  detail  must  be  insisted  on,  if  the  best  results  are  to 
be  expected. 

My  own  experience  with  this  method  has  been  very  satisfactory 
in  surface  wounds,  such  as  are  referred  to  the  plastic  surgeon,  and  my 
remarks  on  the  chlorin  antiseptics  deal  with  them  only  from  that 
standpoint. 

There  are  certain  disadvantages  in  the  use  of  the  hypochlorite  of 
soda  solutions.  The  solution  must  be  prepared  with  extreme  care,  and 
preferably  should  be  made  fresh  each  day,  although  it  will  keep  for  a 
week  or  more. 

The  hypochlorite  solution  will  irritate  the  skin,  if  the  latter  is  not 
carefully  protected.  Only  a  0.48  per  cent  solution  of  the  hypochlorite 
can  be  used  without  causing  irritation. 


THE    TREATMENT    OF    WOUNDS  1 45 

Eusol. — Another  solution  of  chlorin  for  war  wounds  is  the  so-called 
Eusol  (Edinburgh  University  solution),  which  ma>'  be  used  on  com- 
presses, or  by  the  Carrel  technic. 

A  mixture  of  equal  parts  of  boric  acid  and  dry  bleaching  powder 
(chlorinated  lime)  is  made,  and  kept  in  a  tightly  stoppered  bottle.  This 
is  called  Eupad  powder.  Eusol  (which  contains  the  equivalent  of 
about  0.27  per  cent  hypochlorous  acid)  is  made  by  taking  25  grams  of 
Eupad  powder  to  one  liter  of  water.  The  flask  is  well  shaken  and  left 
standing  for  several  hours;  the  solution  is  then  filtered  and  is  ready  for 
use.  It  has  been  used  extensively  by  English  surgeons,  and  excellent 
results  have  been  obtained.  I  have  found  that  patients  complain  of 
more  burning  and  discomfort  in  the  wound  itself  when  Eusol  is  used, 
than  when  Dakin's  solution  is  instilled. 

P.  Duval,  after  long  experimentation,  found  that  Wright's  hyper- 
tonic solution  cleared  up  wounds  with  gangrenous  surfaces  in  from  36  to 
48  hours,  which  is  a  quicker  result  than  can  be  obtained  with  other 
methods,  and  this  has  also  been  my  own  experience.  After  this  length 
of  time  however,  Dakin's  solution,  ether,  or  the  sun's  rays,  give  more 
rapid  sterilization  than  a  continuation  of  Wright's  method. 

DICHLORAMINE-T  (Toluene-para-sulphondichloramine) 

It  was  found  that  Dichloramine-T  also  was  a  powerful  germicide, 
and  that  when  dissolved  in  chlorcosane  (a  chlorinated  oil),  it  could 
be  used  in  a  much  stronger  concentration  than  was  possible  with  Dakin's 
solution. 

Dichloramine-T  in  this  way  can  be  used  in  from  5  to  20  per  cent, 
preferably  7.5  per  cent  solution.  It  is  sprayed  over  the  wound  with  a 
glass  atomizer,  or  may  be  applied  with  a  (dry)  medicine  dropper  or  a 
glass  rod. 

No  watery  or  alcoholic  solutions  should  be  allowed  to  come  in 
contact  with  the  wound,  since  these  fluids  decompose  the  substance. 
If  cleansing  is  necessary,  sterile  alboline,  benzine  or  ether  may  be  used. 

In  Dichloramine-T  we  have  a  chlorin  antiseptic  which  is  easy  to 
prepare.  The  technic  is  simple.  The  dressings  are  done  once  in  24 
hours,  and  are  inexpensive,  only  a  small  amount  of  gauze  being  used. 
No  special  apparatus  is  necessary.  There  is  no  irritation  to  the  skin  if 
the  chemicals  are  properly  prepared,  although  it  is  from  10  to  40  times 
stronger  than  Dakin's  solution. 

The  results  on  surface  wounds  are  good,  and  it  is  especially  valuable 
10 


146  PLASTIC  SURGERY 

in  cases  in  which  the  use  of  the  more  comphcated  technic  of  Carrel 
with  Dakin's  solution  is  impracticable.  Its  action  on  necrotic  tissue 
is  not  as  marked  as  the  hypochlorite  solution,  although  it  has  the 
power  of  dissolving  dead  tissue.  Excellent  reports  on  its  efficiency  in 
the  treatment  of  war  wounds  by  Sweet  and  Hodge,  and  others,  and  in 
the  work  of  Lee  and  Furness  who  used  it  on  infected  wounds  in  civil 
practice,  testify  to  its  worth. 

My  own  experience  with  Dichloramine-T  in  the  Out-patient 
Department  of  the  Johns  Hopkins  Hospital  has  been  quite  satisfactory. 
The  rapid  drying  out  of  the  granulations,  and  the  small  amount  of 
discharge,  being  especially  noticeable. 

In  this  antiseptic  we  have  a  substance  which  can  be  used  with  special 
advantage  in  the  Out-patient  Service.  It  is  clean  and  economical,  and 
certainly  aids  in  the  disinfection  of  infected  wounds.  One  is  struck  by 
the  lack  of  disagreeable  odors  when  visiting  a  ward  in  which  any  of  the 
chlorin  antiseptics  are  being  used,  and  this  deodorizing  feature  alone 
would  make  the  use  of  these  substances  well  worth  trying. 

There  is  a  wide  field  for  the  use  of  chlorin  germicides.  In  extensive 
deep  wounds.  Carrel's  method  of  using  Dakin's  solution  is  undoubtedly 
the  best,  but  in  many  instances  in  which  it  is  impossible  to  carry  out 
this  technic,  Dichloramine-T  may  be  used  with  satisfaction. 

Quino-fonnol. — Pilcher  has  recently  reported  the  effect  on  war 
wounds  of  a  solution  called  quino-formol,  which  is  apphed  by  the 
Carrel  method.  The  formula  is  as  follows:  Quinin  sulphat  i.gram; 
hydrochloric  acid  0.50  c.c,  glacial  acetic  acid  (99  per  cent)  5.00  c.c, 
sodium  chlorid  17.50  grams,  formol  (40  per  cent)  i.oo  c.c,  thymol 
0.25  grams,  alcohol  (90  per  cent)  15.00  c.c,  water  q.s.  ad  i  liter,  (i) 
Dissolve  the  quinin  in  the  hydrochloric  and  acetic  acids;  (2)  dissolve 
the  sodium  chlorid  in  the  water;  (3)  dissolve  the  thymol  in  the  alcohol. 
Add  No.  I  and  No.  2,  then  the  formol  and  finally  the  thymol  solution. 

The  hydrochloric  acid,  as  noted  in  the  formula,  is  used  to  put 
the  quinin  in  a  more  perfect  solution;  the  acetic  acid  for  its  action  with 
the  quinin  solution,  giving  a  solvent  and  analgesic  effect;  the  sodium 
chloride  for  its  dehydrating  properties;  the  formol  for  its  bactericidal 
and  fixing  properties,  as  is  the  alcohol,  which  is  used  to  put  the  thymol 
into  solution. 

Among  the  many  advantages  claimed  are,  that  the  solution  is 
stable,  is  easily  prepared,  and  can  be  used  in  the  evacuation  hospital. 
The  wound  is  rapidly  sterilized  and  epithelization  is  stimulated.  The 
solution   has   no   proteolytic   properties   and  if  there  is  deposition  of 


THE    TREATMENT    OF    WOUNDS  I47 

fibrin,  then  Dakin's  solution  should  be  used  until  the  wound  is  clear 
of  detritus. 

I  have  had  no  personal  experience  with  this  solution,  but  such 
excellent  results  are  reported  that  it  seems  well  worth  a  trial. 

Ointments 

The  ointments  most  commonly  used  on  granulating  wounds  are, 
boric  acid  (lo  per  cent),  balsam  of  Peru  (20  per  cent),  salicylic  acid 
(2  to  5  per  cent),  ammoniated  mercury  (10  per  cent),  blue  ointment 
{^^  per  cent),  iodoform  ointment  (10  per  cent),  zinc  oxid  ointment 
(20  per  cent),  either  in  vaselin  or  in  benzoinated  lard.  I  often  use  a 
thick  paste  of  bismuth  subnitrat  and  castor  oil  and  find  it  a  valuable 
dressing.  The  ointments  should  be  applied  on  old  linen,  or  close  meshed 
gauze,  and  should  not  extend  more  than  2.5  cm.  (i  inch)  beyond  the 
wound  edges. 

Powders 

Powders  are  used  for  hastening  the  drying  of  surface  wounds;  for 
dusting  over  sutured  wounds,  for  preventing  maceration  in  skin  folds, 
and  protecting  the  skin  from  secretions.  Unless  a  wound  is  very  super- 
ficial, I  scarcely  ever  use  powder  of  any  sort,  as  crusts  form,  and  if  the 
wound  is  large  it  is  hard  to  prevent  absorption  from  the  secretions  which 
collect  beneath  the  crusts.  I  have  found  the  use  of  powder  much  less 
satisfactory  than  exposure  to  the  sun  or  electric  light,  and  in  the  latter 
case  the  wound  is  not  clogged  to  the  same  extent. 

The  most  satisfactory  use  of  powder  is  for  the  protection  of  the 
healthy  skin,  and  for  this  purpose  I  use  the  ordinary  talcum,  or  stearat 
of  zinc  powder,  the  former  to  dust  over  the  skin,  more  for  comfort,  and 
the  latter,  which  is  an  oily  powder,  to  protect  the  skin  from  secretions 
and  from  maceration.  Calomel  powder,  or  subiodid  of  bismuth,  may 
be  used  on  a  sutured  wound  which  is  exposed  to  the  air,  and  I  occasion- 
ally use  bismuth  subnitrat,  bismuth  subgallat,  iodoform,  and  boric 
powders,  either  alone  on  in  combination. 

Medicated  Gauze 

Gauze  impregnated  with  iodoform,  bismuth  subnitrat,  or  balsam 
of  Peru,  are  those  commonly  used  for  surface  wounds. 

I  have  had  very  satisfactory  results  in  clearing  up  infected  surface 


148  PLASTIC    SURGERY 

wounds  by  the  use  of  gauze  saturated  with  a  mixture  of  camphor  51 
parts,  pure  carbolic  acid  49  parts. 

Wet  Dressings 

Many  solutions  have  been  used  for  irrigations,  and  for  wetting 
gauze  dressings.  Among  them,  normal  salt;  Ringer's;  Wright's;  sterile 
water;  saturated  boric;  Dakin's  hypochlorite  of  soda;  acetate  of  alu- 
minum 2  to  5  per  cent;  benzoic  acid  2  per  cent;  glucose  48  per  cent; 
iodin  1-500  (tincture  of  iodin  15.C.C.;  water  485.  c.c);  alcohol  25  to 
70  per  cent;  permanganate  of  potash  1—5000  to  1-50;  picric  acid  0.2 
to  I  per  cent;  nitrate  of  silver  1-100,000;  carbolic  acid  i— 100  to  1-40; 
bichlorid  of  mercury  1-10,000  to  i-iooo;  magnesium  sulphat,  satu- 
rated solution;  Delbet's  anhydrous  chlorid  of  magnesium  12.1  parts, 
water  1000  parts,  and  others.  All  of  these  solutions  are  useful  for 
different  purposes. 

On  open  wounds  many  of  the  wet  dressings  are  used  to  inhibit  the 
growth  of  bacteria  through  the  antiseptic  properties  of  the  solution. 
Certain  wet  dressings  stimulate  the  free  flow  of  lymph,  and  thus 
mechanically  wash  away  the  bacteria.  With  the  exception  of  the  sugar 
solution,  these  dressings  are  usually  applied  hot,  and  thus  the  circula- 
tion is  improved  and  the  physiological  processes  are  stimulated.  Where 
compresses  are  used  on  infected  wounds,  they  should  be  changed  every 
2  to  3  hours. 

I  frequently  use  25  to  70  per  cent  alcohol  dressings,  varying  the 
the  strength  according  to  conditions,  and  find  it  very  satisfactory 
in  cleaning  up  a  sluggish  wound.  Permanganate  of  potash  (1-50) 
also  makes  a  splendid  dressing  for  deodorizing  and  stimulating  in  such 
cases. 

Dressings  wet  with  normal  salt  solution,  or  sterile  water,  are  often 
more  effective  than  those  with  antiseptic  solutions".  At  one  time 
bichlorid  of  mercury  (i-iooo)  was  the  favorite  antiseptic  solution  for 
wet  dressings.  Fortunately,  the  indiscriminate  use  of  this  solution 
in  such  strength  has  been  abandoned,  as  it  often  caused  severe  burning 
of  the  surrounding  skin,  and  in  addition,  although  the  antiseptic  action 
was  satisfactory,  there  was  little  gain  made  in  the  process  of  healing  so 
long  as  the  use  of  this  solution  was  continued. 

I  must  take  this  opportunity  of  speaking  of  the  danger  of  putting 
up  an  extremity  in  a  wet  carbolic  dressing  (even  though  its  strength 
is  very  weak,  0.5  to  i  per  cent),  on  account  of  the  danger  of  gangrene 
which  often  follows. 


THE    TREATMENT    OF    WOUNDS  149 

The  Continuous  Tub. — The  continuous  tub,  first  used  in  the  treat- 
ment of  burns  by  Passavant  in  1857  (A.  Rose),  is  often  employed  in  the 
treatment  of  very  extensive  infected  granulating  wounds,  whatever 
may  be  their  cause.  •  The  patient,  supported  on  pro]:)er  slings  (usually 
in  a  portable  tub,  such  as  is  used  for  a  typhoid  bath)  is  placed  in  water 
kept  at  body  temperature,  or  slightly  warmer  (made  faintly  alkaline 
with  sodium  bicarbonate).  Potassium  permanganate  (6. to  8. grams 
to  the  tub),  may  be  used  instead  of  the  soda,  in  badly  infected  cases. 
It  is  not  advisable  to  keep  the  patient  in  the  tub  too  long,  half  an  hour 
being  sufhcient  for  a  beginning.  Later,  the  time  may  be  gradually 
increased,  and  the  patient  may  stay  in  for  days  without  ill  effects. 
If  the  general  condition  is  not  satisfactory,  the  heart  should  be  care- 
fully watched,  as  occasionally  collapse  occurs  during  an  immersion. 
The  normal  skin  should  be  anointed  with  lanolin,  or  some  similar  sub- 
stance, to  prevent  maceration,  when  long-continued  tubbing  is  used. 

The  tub  is  of  great  value  in  softening  the  crusts  which  often  form 
where  granulating  wounds  are  treated  by  the  open-air  method.  After 
a  short  time  in  the  tub,  the  crusts  may  be  sponged  off  without  pain  or 
bleeding.  Adherent  dressings  may  also  be  removed  without  difficulty 
after  a  soaking  in  a  tub.  Compresses  wet  with  normal  salt  or  boric 
solution,  or  with  i  per  cent  hydrogen  peroxid,  may  also  be  used  for 
removing  crusts. 

Following  the  proper  use  of  the  continuous  tub  I  have  seen  remark- 
able improvement  in  the  condition  of  the  wound  as  well  as  in  the  general 
condition  of  the  patient.  In  my  opinion  it  is  simply  a  valuable  auxi- 
liary to  other  methods  of  wound  treatment  and  should  be  used  only  in 
selected  cases.  The  principle  of  the  continuous  tub  may  be  utilized 
in  the  treatment  of  injuries  of  the  extremities,  by  immersing  the  ex- 
tremity only. 

Paraffin  Wax  in  the  Treatment  of  Granulating  Wounds 

Paraffin  wax  for  the  treatment  of  burns  was  first  used  by  Berthe 
de  Sandford.  In  1910  some  of  his  secret  preparation,  Ambrine,  was 
brought  to  the  Johns  Hopkins  Hopital,  and  I  was  able  to  try  it  out 
quite  thoroughly.  The  importance  of  drying  the  surface  on  which  the 
melted  wax  was  to  be  placed  was  not  at  that  time  appreciated.  I 
used  the  wax  on  all  sorts  of  wounds,  and  although  the  results  obtained 
were  not  startling,  they  were  very  encouraging.  The  supply  of  material 
was  soon  exhausted,  and  no  more  was  available. 


150  PLASTIC    SURGERY 

Carrel,  in  191 1,  while  studying  the  healing  of  wounds,  compounded 
a  flexible  paraffin  mixture.^  This  dressing  I  have  used  instead  of 
ambrine  ever  since  with  great  satisfaction. 

The  use  of  ambrine  on  war  burns  has  been  exploited  in  the  "Press," 
and  has  focused  the  attention  of  the  profession  on  the  value  of  paraffin 
dressings  in  treating  burns  or  large  granulating  surfaces. 

As  the  formula  of  ambrine  is  secret^  and  its  price  exorbitant,  many 
paraffin  wax  mixtures  have  made  their  appearance  on  the  market, 
or  have  been  reported  in  the  journals,  and  several  of  these  are  very 
satisfactory.  Numerous  excellent  papers  on  the  use  of  paraffin  wax 
have  appeared  in  the  last  three  years. 

The  requirements  of  a  successful  mixture  are,  that  it  should  be 
neutral  in  reaction,  flexible,  adhesive,  and  cheap. 

Method  of  Application.— The  wound  should  be  dried  thoroughly 
with  an  electric  hot-air  drier,  an  electric  fan,  or  even  an  ordinary  fan, 
will  serve  the  purpose,  until  there  is  no  moisture  on  the  surface.  If 
blebs  are  present,  they  should  be  punctured,  but  not  excised. 

The  sterilized  melted  wax  should  then  be  sprayed  over  the  entire 
surface  of  the  wound,  with  a  margin  on  the  surrounding  skin.  A 
double-jacketed  (special)  atomizer,  heated  by  electricity,  or  hot  water 
is  used  for  this  purpose.  If  an  atomizer  is  not  available,  the  melted 
mixture  may  be  gently  daubed  on  with  a  broad,  soft  camels-hair 
brush. 

The  application  is  practically  without  pain,  and  when  the  atomizer 
is  used  there  is  no  danger  of  burning,  but  if  the  brush  is  employed,  the 
temperature  should  not  be  above  i5o°F.  After  the  first  coat  has  been 
applied  over  the  entire  surface,  a  thin  sheet  of  cotton  is  placed  over  the 
wax  coating,  and  this  is  also  saturated  with  the  paraffin,  making  the 
entire  dressing  a  single  mass.  Over  this  is  placed  cotton  and  a  bandage. 
The  part  should  be  immobilized,  and  the  dressings  changed  every  24 
hours.  The  warm,  non-adherent,  sealed  dressing  has  a  remarkable 
effect  on  the  growth  of  epithelium,  which  is  very  rapid. 

The  wax  mixture  may  be  used  plain,  or  have  incorporated  in  it 
various  substances,  such  as  Beta-naphthol,  oil  of  eucalyptus,  acriflavin, 
scarlet  red,  etc.     I  have  had  good  results  with  the  Beta-naphthol,  as 

1  Formula. — Paraffin  (52°)  18.  grams;  paraffin  (40°)  6.  grams;  beeswax  2.  grams;  castor 
oil  2.  c.c.     Mix.     Sterilize  in  the  autoclave  and  apply  at  body  heat. 

2  Ambrine  is  now  said  to  be  composed  of  gutta-percha  6  to  10  per  cent,  and  paraffin 
(SS°)  90  to  94  per  cent.  The  mixture  with  the  larger  percentage  of  gutta-percha  is  more 
flexible. 


THE    TREATMENT    OF    WOUNDS  151 

it  seems  to  aid  in  controlling  infection.  Scarlet  red  (4  to  8  per  cent) 
incorporated  in  the  wax,  undoubtedly  aids  in  stimulating  epithelial 
growth. 

The  method  has  many  advantages.  It  is  simple  to  apply,  and  with 
proper  facilities  requires  little  time.  The  application  usually  causes 
no  discomfort,  and  often  relieves  pain  which  may  previously  have 
existed.  The  changes  of  dressing  are  painless,  as  the  cotton  paraffin 
shell  can  be  removed  without  difficulty,  and  there  is  no  injury  to  either 
granulation  tissue  or  growing  epithelium. 

In  wards  where  this  dressing  is  used,  the  odor  is  at  times  very 
disagreeable. 

Secretions  may  be  removed  with  irrigations  of  boric  or  salt  solution 
or  mopped  oft*  with  cotton  pledgets.  When  there  is  much  necrosis  or 
where  infection  is  severe,  the  wound  must  be  put  in  proper  condition 
by  the  use  of  the  chlorin  antiseptics  or  one  of  the  other  methods, 
before  the  paraffin  wax  is  applied. 

The  cicatrix  following  the  healing  after  the  use  of  the  paraffin  is 
smooth  and  flexible  and  does  not  seem  to  have  the  same  tendency  to 
contract.  I  have  not  been  favorably  impressed  with  paraffin  as  an 
early  dressing  for  small  deep,  or  Ollier-Thiersch,  skin  grafts,  especially 
if  they  have  been  placed  on  a  granulating  surface.  After  the  grafts 
have  become  firmly  established,  the  paraffin  wax  mixtures  can  be  used 
with  advantage  and  rapid  epithelial  growth  will  follow,  both  from  the 
grafts  and  the  wound  edges.  On  a  whole-thickness  graft,  however, 
which  fills  a  clean  defect,  they  can  be  used  with  satisfaction.  I  have 
left  some  of  these  dressings  undisturbed  for  as  long  as  two  weeks. 

The  Use  of  Adhesive  Plaster 

Adhesive  plaster  is  one  of  the  most  valuable  of  our  surgical  dressing 
materials.  The  kind  now  almost  universally  used  is  the  so-called  zinc 
oxid  plaster,  as  it  is  less  irritating  to  the  skin  than  ordinary  adhesive 
plaster.  This  may  be  obtained  either  perforated  or  unperforated. 
Before  adhesive  plaster  is  applied  the  part  should  be  shaved. 

Adhesive  plaster  is  also  used  as  a  dressing  immediately  next  to  a 
granulating  wound,  either  in  one  piece,  or  in  overlapping  strips.  When 
used  in  this  way  it  provides  a  closed  method  and  acts  very  much  as  do 
the  paraffin  mixtures,  as  it  does  not  stick  to  the  wound  and  holds  in 
heat  and  moisture. 

Often  granulations  may  be  flattened  by  its  use.  and  when  space  is 


152  PLASTIC    SURGERY 

allowed  between  the  strips,  or  perforations  are  made,  the  adhesive  is 
simply  a  bland  non-adherent  dressing.  If  the  ends  of  the  plaster  are 
allowed  to  extend  quite  a  distance  beyond  the  wound  margin,  or  around 
the  part,  we  then,  in  addition,  have  the  advantage  of  support.  I  have 
used  scarlet  red  on  zinc  oxid  adhesive  plaster  with  success. 

The  skin  of  some  individuals  is  irritated  by  even  zinc  oxid  plaster^ 
and  for  this  reason  in  applying  the  plaster,  care  must  be  taken  not  to 
place  it  over  exactly  the  same  area  twice  in  succession. 

Adhesive  plaster  with  its  crinoline  facing  can  be  wrapped  and  ster- 
ilized in  the  autoclave  with  the  ordinary  dressings.  Sterile  adhesive 
plaster  may  also  be  purchased  in  packages. 

For  ordinary  purposes  (such  as  strapping  leg  ulcers),  zinc  oxid  ad- 
hesive plaster  can  be  passed  several  times  through  an  alcohol  flame, 
and  be  rendered  practically  sterile.  Adhesive  plaster  is  of  great  use 
in  relieving  tension,  by  supporting  surrounding  tissues. 

The  plaster  should  be  removed  with  as  little  pain  as  possible.  I 
find  that  ordinary  gasolin  or  benzin  is  most  satisfactory  for  removal, 
as  it  is  efHcient,  cheap,  and  easy  to  obtain.  The  end  of  the  plaster 
should  be  started,  and  then  the  gauze  pledget,  wet  with  gasolin,  should 
be  applied  to  its  under  surface  as  it  is  raised  and  to  the  skin.  It  will 
then  be  found  that  by  continuing  this  process,  the  plaster  can  be  taken 
off  with  little  pain.  If  the  gasolin  is  put  on  over  the  fabric  of  the 
plaster,  this  can  easily  be  removed,  but  the  adhesive  material  will  be 
left  on  the  skin,  and  must  be  subsequently  washed  off  with  gasolin. 

Ether,  oil  of  wintergreen  and  kerosene  oil  will  also  remove  adhesive 
plaster,  but  each  has  its  disadvantages.  Ether  is  expensive  and  the 
odor  is  objectional  to  many  patients.  Oil  of  wintergreen  is  expensive 
and  often  unavailable.  Kerosene  oil  leaves  the  skin  greasy  and  has 
to  be  removed  before  adhesive  plaster  can  again  be  applied. 

The  Open  Treatment  of  Wounds 

Heliotherapy. — The  exposure  of  infected  wounds  to  sunhght  or 
electric  light  and  air  has  been  advocated  by  many. 

It  is  advisable  that  the  part  be  immobilized.  In  surface  wounds  the 
position  should  be  such  that  secretions  may  gravitate,  and  be  caught 
at  the  most  dependent  portion  (Fig.  119). 

The  wound  should  be  directly  exposed  to  the  sunlight,  if  possible, 
without  the  interposition  of  gauze.  It  is  most  important  that  it  be 
gradually   accustomed    to    the    sun's   rays,    otherwise   newly   formed 


THE    TREATMENT    OF    WOUNDS 


153 


epithelium  or  recently  healed  grafts  may  be  blistered  and  even  de- 
stroyed. The  first  exposure  should  be  limited  to  15  minutes  and  the 
time  be  gradually  increased  to  5  or  6  hours.  Acute  sunburn  should  be 
avoided.  Wire  cages  over  the  wounds  and  mosquito-netting  to  prevent 
contamination  by  flies,  are  often  advantageous. 

Some  of  the  advantages  of  this  method  are  the  relief  of  pain, 
painless  dressings,  bactericidal  action  of  sunlight,  a  copious  oozing  and 
increase  of  phagocytosis,  the  rapid  casting  off  of  necrotic  tissue  by 
healthy  granulations,  and  economy  in  dressings. 


Pig.  119. — Method  of  using  plaster  of  Paris  as  a  cage  over  an  extensive  burn  of  the  leg 
and  lower  third  of  the  thigh. — This  cage  allows  exposure  to  the  light  and  air,  and  also  holds 
the  limb  extended  in  those  cases  where  contracture  is  feared.  Wire  netting  around  the 
ribs  of  the  cage  may  be  used  \\'ith  advantage. 


All  sorts  of  wounds  have  been  treated  by  this  method  with  success. 
It  is  said  that  the  luminous  rather  than  the  chemical  rays  are  the  most 
active  in  their  eft"ect  on  wounds.  Whether  it  is  the  heat  or  dryness  and 
consequent  bactericidal  action,  or  both,  or  whether  it  is  the  lack  of 
injury  to  growing  tissues  which  necessarily  must  take  place  in  the 
course  of  ordinary  wound  dressings,  it  is  hard  to  say. 

My  own  experience  with  sunlight  has  been  favorable  in  certain 
wounds,  but  I  have  seen,  at  times,  extensive  burns  treated  by  this 
method  in  which  the  granulations  became  covered  with  a  thick  crust, 
beneath  which  pus  was  confined,  and  thus  the  entire  benefit  of  the  treat- 
ment was  lost. 

It  is  of  great  importance  that  the  surface  of  these  wounds  be  kept 
clean,  if  this  method  is  to  be  used  successfullv.     In  extensive  wounds 


154  PLASTIC    SURGERY 

with  accumulation  of  secretion,  it  may  be  necessary  to  put  the  patient 
in  a  tub  for  a  short  time  each  day  to  soften  the  crusts,  before  exposing 
the  wound  to  the  sun. 

Many  times  sunHght  is  not  available,  and  in  such  cases  excellent 
results  may  be  obtained  by  the  exposure  of  the  wound  to  electric  light. 
This  may  be  done  with  little  trouble,  by  suspending  one  or  more  electric 
bulbs  on  a  frame  which  holds  the  bedclothes  from  the  part.  The 
exposure  may  then  be  made  as  desired,  sometimes  for  many  hours  at 
a  time.  The  temperature  should  not  be  less  than  90°  or  more  than 
ioo°F.  A  black  cloth  may  be  placed  over  the  rack  if  the  continuous 
light  is  irksome  to  the  patient's  eyes.  I  have  found  the  use  of  electric 
light  to  be  especially  satisfactory  in  drying  out  edematous  granulations, 
and  there  is  little  doubt  but  that  it  produces  a  stimulation  of  epithelial 
growth,  both  from  the  wound  edges,  and  from  any  grafts  which  may  be 
present.  Sometimes,  when  the  extreme  drying  is  disagreeable,  a  spray 
of  sterile  liquid  albolene  is  soothing. 

Hot  Air  in  the  Treatment  of  Granulating  Wounds. — I  have  had 
considerable  success  in  the  stimulation  of  healing  in  sluggish  ulcers  from 
the  use  of  baking  in  an  electrically  heated  hot-air  apparatus,  in  which  the 
temperature  could  be  regulated.  The  exposures  were  begun  with  10 
minutes  at  a  temperature  of  i5o°F.,  and  gradually  increased  in  time 
to  an  hour,  with  temperatures  up  to  200°  or  25o°F.  The  baking  proc- 
ess should  be  continued  every  day,  some  bland  dressing  being  applied 
during  the  intervals. 

In  wounds  that  resist  exposure  to  various  forms  of  hot  air  and  other 
methods  of  stimulation,  hot-air  douches  given  every  day  will  often  accel- 
erate healing.  The  beneficial  action  is  probably  due  to  the  stimulating 
effect  of  the  impact  of  the  air  against  the  wound,  the  hyperemia  induced, 
and  also  to  the  drying  of  the  wound  by  the  air  douche.  The  bacterial 
count  is  rapidly  diminished,  there  is  relief  of  pain,  the  granulations 
become  firm,  the  secretions  become  scanty,  and  the  epithelium  is  stimu- 
lated.    The  healing  is  rapid  and  the  scar  is  smooth  and  flexible. 

Many  kinds  of  apparatus  have  been  used  for  this  purpose,  from  a 
simple  hand  pump  to  the  complicated  apparatus  devised  by  Kiittner. 
I  have  had  very  good  results  with  a  simple  Foen  apparatus,  in  which  the 
air  is  forced  by  an  electrically  driven  fan  over  a  heated  coil.  With 
this  apparatus  the  air  may  be  either  hot  or  cold,  as  seems  desirable,  but 
I  have  usually  found  the  hot  douche  preferable.  Exposure  to  the  cur- 
rent of  air  induced  by  an  ordinary  electric  fan  is  also  useful. 

The  douche  should  be  used  each  day,  beginning  with  10  minutes, 


THE    TREATMENT    OF   WOUNDS  1 55 

and  gradually  increasing  the  time  to  45  minutes;  the  intensity  of  the 
heat  should  be  regulated  by  the  feelings  of  the  patient. 

Balsam  of  Peru 

Balsam  of  Peru  is  most  useful  as  a  surgical  dressing.  It  can  be 
poured  into  fresh  wounds,  and  will  differentiate  within  24  hours  the 
tissues  which  will  survive.  The  devitahzed  tissues  will  be  mummified, 
and  can  then  be  excised.  It  has  been  said  that  balsam  of  Peru,  if  used 
in  considerable  quantities  will  have  a  depressing  effect  on  the  function 
of  the  kidneys,  but  after  years  of  experience  with  it  I  have  not  seen  this 
untoward  result. 

Balsam  of  Peru  is  one  of  the  best  drugs  to  stimulate  granulation 
tissue.  It  has  a  shght  antiseptic  action,  is  an  excellent  deodorizer,  and 
will  soon  clear  up  gangrenous  and  necrotic  surfaces.  It  is  used  either 
undiluted  on  gauze,  or  mixed  with  castor  oil,  i  to  3,  or  i  to  4.  It  is 
also  used  as  an  ointment,   10  to  20  per  cent  in  petrolatum. 

The  Embalmment  Treatment  of  Septic  Wounds  (Menciere) 

Menciere  recommends  the  following  treatment  for  septic  wounds: 
Wash  the  wound  successively  with  solutions  of  bichlorid  of  mercury 
i-iooo;  carbolic  acid  1-40;  hydrogen  peroxid  1-3.  Then  dress 
with  gauze  saturated  with  an  "embalming"  mixture  of  iodoform,  guai- 
acol  and  eucalyptol  each  10  parts;  balsam  of  Peru  30  parts;  ether  100 
parts.  The  wound  should  be  washed  for  the  first  three  or  four  days 
with  the  three  antiseptics,  which  are  used  because  each  one  is  par- 
ticularly adapted  to  a  peculiar  microbial  variety.  The  usual  dressing 
is  then  applied.  After  this  only  peroxid  of  hydrogen  (1-3  or  1-4) 
should  be  used  for  irrigations  on  account  of  the  destructive  action  of 
bichlorid  and  carbolic  acid  on  the  cells. 

The  wounds  may  also  be  irrigated  with  the  embalming  mixture 
which  contains  1000  parts  of  ether,  instead  of  100  parts.  This  method 
is  an  excellent  one,  and  I  have  used  it  with  great  success  in  cleaning 
and  stimulating  granulating  wounds. 

The  Use  of  Ether  in  the  Treatment  of  Woimds 

I  have  used  ether  for  several  years  for  washing  granulating  surfaces 
and  have  found  it  very  satisfactory  as  a  cleanser.     Patients  complain 


156  PLASTIC    SURGERY 

of  the  coldness  due  to  the  evaporation,  but  the  application  causes  no 
pain  either  when  it  is  poured  on,  or  when  the  wound  is  mopped  with  it. 
I  have  found  that  gauze  saturated  with  a  mixture  of  equal  parts  of 
ether  and  castor  oil,  and  covered  with  rubber  protective  (which  is  made 
adherent  to  the  skin  with  a  few  drops  of  chloroform)  causes  diminution 
of  pain  and  also  is  effective  in  reducing  exuberant  granulations  or 
in  cleansing  infected  wounds.-  These  dressings  can  be  removed  without 
pain,  and  should  be  changed  at  least  once  in  24  hours,  preferably  every 
12  hours,  as  the  ether  soon  evaporates.  If  desired,  camphor  or  balsam 
of  Peru  may  be  added  to  the  mixture  (camphor  i.gram  to  100.  c.c; 
balsam  of  Peru  2.  c.c.  to  100.  c.c). 

Ether  is  often  used  in  cleansing  war  wounds  and  fresh  industrial 
wounds,  so  that  many  of  these  may  be  successfully  closed  immediately 
after  being  scrubbed  with  it. 

Ether  destroys  the  red  corpuscles  in  the  wound  and  also  dissolves 
the  fats  and  certain  alkaloids.  It  is  said  that  in  this  way  the  phagocytes 
ar&  left  unhampered,  and  that  autosterilization  of  the  wound  occurs. 

Delbet  and  Richard  have  used  ether  as  a  dressing  by  applying  it 
several  times  a  day  through  tubes  which  penetrate  the  dressing.  They 
use  from  10.  to  40.  c.c.  at  each  time,  and  regard  the  procedure  as  a 
supplement  to  dry  aseptic  technic. 

I  have  found  the  following  to  be  a  satisfactory  method  of  carrying 
this  out:  A  flat  gauze  dressing  of  the  desired  thickness  is  applied, 
and  over  this  a  considerably  larger  piece  of  rubber  dam,  through  which 
one  or  two  Carrel  tubes  are  inserted,  an  effort  being  made  to  make  the 
junctions  air  tight.  The  tubes  are  arranged  so  that  they  lie  lengthways 
on  the  gauze  below.  The  edges  of  the  rubber  dam  are  then  secured  to 
the  skin  with  adhesive  plaster,  over  which  is  placed  a  sort  of  ring, 
made  of  gauze,  felt,  or  cotton,  which  comes  to  the  edge  of  the  gauze 
dressing  beneath  the  rubber  dam,  but  not  over  it,  and  being  somewhat 
thicker,  projects  above  it.  Over  the  whole  is  placed  gauze  and  a  snug 
bandage.  Every  4  hours  ether  is  injected  into  the  tubes,  which  are 
then  pinched  off.     In  this  way  evaporation  is  somewhat  delayed. 

Glycerin  as  a  Dressing  for  Infected  Wotinds 

Ruska  recently  again  called  attention  to  the  value  of  glycerin  as  a 
dressing  for  infected  wounds.  Its  hygroscopic  action  tends  to  dry 
edematous  granulation  tissue,  and  aids  materially  in  bringing  an 
infected  granulating  surface  into  a  healthy  condition.     He  uses  it  on 


THE    TREATMENT    OF    WOUNDS  157 

compresses,  over  which  is  placed  an  air-tight  dressing.  The  use  of 
undikited  glycerin  in  my  hands  has  been  most  satisfactory  for  reducing 
edematous  granulation  tissue  and  as  a  dressing  for  infected  wounds. 
Glycerin  itself  has  a  slight  antiseptic  action,  and  if  more  vigorous 
antiseptic  action  is  desired,  iodin,  or  any  other  suitable  antiseptic 
substance,  can  be  added  to  it.  The  dressings  should  be  changed  twice 
a  day. 

Iodin  in  the  Treatment  of  Wounds 

Long  before  the  value  of  iodin  as  a  skin  disinfectant  (as  developed 
by  Grossich)  was  realized,  this  metal  was  used  either  as  the  tincture  or 
in  some  other  form,  in  the  treatment  of  wounds.  In  a  i  to  500  watery 
solution  it  is  used  for  irrigations  and  for  saturating  gauze  dressings. 
The  tincture  is  used  for  the  disinfection  of  sinuses,  and  for  swabbing 
abscesses. 

Vaporized  iodin  has  been  used  for  years.  The  metallic  iodin  is 
vaporized  by  heat,  and  then  blown  over  the  wound  surface,  where  it  is 
deposited  and  without  doubt  stimulates  sluggish  wounds  while  controll- 
ing infection. 

Iodoform  in  gauze,  as  a  powder,  and  in  emulsion  and  ointments 
has  been  freely  used.  The  use  of  this  substance  has  been  abandoned 
by  many  on  account  of  its  odor,  but  I  wish  to  state  without  reservation 
that  on  certain  wounds  iodoform  will  produce  better  results  than  can 
be  secured  by  any  other  method  of  treatment.  The  antiseptic  action 
of  dry  iodoform  powder  itself,  has  been  proved  (in  the  laboratory), 
to  be  of  little  value,  but  clinically,  in  contact  with  the  wound  secret- 
ions' it  is  without  doubt  a  most  valuable  therapeutic  agent. 

The  Bipp  Treatment  of  Wounds 

(Bismuth — Iodoform — Petrolatum — Paste) 

R.  M orison  reported  the  use  of  a  mixture  of  bismuth  subnitrat 
I  part,  iodoform  2  parts,  and  liquid  petrolatum  in  suihcient  quantity 
to  make  a  thick  paste  (this  paste  is  not  specially  sterilized).  After 
the  usual  preliminary  treatment  of  thorough  opening  and  excision, 
the  wound  is  filled  with  this  paste,  which  is  rubbed  into  the  tissues, 
and  then,  after  the  excess  has  been  wiped  out,  the  wound  is  dressed  with 
sterile  gauze  or  is  closed  immediately  in  suitable  cases. 

Since  Morison's  early  report  quite  a  number  of  wounds  have  been 
treated  by  the  bismuth  iodoform  paste  method,  and  many  surgeons  are 


150  PLASTIC    SURGERY 

enthusiastic  as  to  its  efficacy.  This  mixture  can  be  used  in  places  where 
facilities  for  the  other  more  complicated  methods  are  not  obtainable. 
It  is  undoubtedly  of  great  service  both  in  civil  and  in  war  practice,  on 
both  fresh  and  granulating  wounds,  although  it  must  be  admitted  that 
a  number  of  cases  of  bismuth  and  iodoform  poisoning  have  been  re- 
ported following  its  use. 

The  Treatment  of  Wounds  with  Sugar 

Sugar  has  been  used  in  the  treatment  of  wounds  since  the  earliest 
times.  Galen  is  said  to  have  used  honey  on  fetid  wounds.  Recently, 
attention  has  again  been  called  to  its  value  as  a  dressing.  Magnus 
found  that  89  per  cent  of  the  sugar  obtained  in  the  open  market  was 
sterile  and  that  no  germs,  except  the  ordinary  saprophytes,  were  found 
in  any  of  the  samples  tested. 

The  simplest  method  is  to  cover  the  wound  with  a  thick  layer  of  sugar 
Cgranulated  or  pulverized;,  over  which  a  dry  dressing  is  placed.  The 
dressings  should  be  changed  at  least  once  a  day.  Glucose  in  a  48  per 
cent  solution,  has  also  been  tried,  and  is  useful  as  a  wet  dressing,  but 
must  be  changed  every  12  hours,  if  the  best  results  are  to  be  obtained. 

Whitehouse  used  a  glucose  solution  (strength  not  stated),  which 
contained  carbolic  acid  fi-8oj  and  reported  excellent  results. 

Probably  the  chief  value  of  the  sugar  treatment  lies  in  the  fact  that 
very  powerful  osmosis  is  set  up,  and  this  floods  the  wound  with  secretions 
until  the  osmotic  tension  is  equalized. 

In  addition  to  its  osmotic  action,  sugar  has  definite  antiseptic  and 
antifermentative  powers.  The  dressings  are  painless  and  do  not  stick 
on  account  of  the  profuse  discharge. 

Sugar  (4  to  8  per  cent)  may  also  be  used  in  petrolatum  ointment, 
with  or  without  i  per  cent  iodoform  (d'Emidio). 

Hercker  reported  over  1000  war  wounds  successfully  treated  with 
sugar,  and  says  that  the  profuse  oozing  from  the  wound  caused  by  the 
sugar  does  away  with  the  necessity  of  irrigations. 

]\Iy  own  experience  with  sugar  as  a  wound  dressing  has  been  con- 
fined to  its  use  on  ulcers  of  long  duration.  There  is  no  doubt  that  it 
causes  profuse  discharge  from  the  wounds,  with  subsequent  stimulation 
of  granulations.  The  dressings  should  be  changed  each  day.  In  warm 
weather  sugar  should  not  be  used  in  the  Out-Patient  Department,  for 
obvious  reasons. 


THE    TREATMENT   OF    WOUNDS  1 59 

The  Use  of  Salt  Packs  and  Sea  Water 

In  order  to  promote  osmosis  and  to  cause  a  free  flow  of  lymph,  salt 
packs  have  been  used  by  Hull  and  others.  The  salt  is  placed  in  bags 
of  suitable  sizes  made  of  four  layers  of  gauze,  and  these  are  laid  on  the 
wound.  The  dressing  is  somewhat  painful  and  has  little  advantage 
over  sugar  used  for  the  same  purpose. 

Abadie  finds  that  concentrated  solutions  of  sea  water  make  a  very 
useful  dressing  for  war  wounds,  after  the  necessary  excision  has  been 
done.  He  irrigates  the  wound  with  a  0.7  per  cent  solution  of  sea  water, 
and  then  packs  with  gauze,  saturated  with  a  14  to  a  28  per  cent  solution 
of  concentrated  sea  water.  Osmosis  is  stimulated,  and  wounds  rapidly 
become  healthy. 

I  have  not  had  an  opportunity  of  using  concentrated  sea  water, 
but  it  should  be,  at  least  as  efficient  as  salt  solution  of  the  same  strength. 

Normal  Serum  in  the  Treatment  of  Woxmds 

Lignieres  reports  remarkable  results  in  the  rapidity  of  healing  of 
wounds  treated  with  compresses  dipped  in  serum,  obtained  under 
sterile  precautions,  which  are  changed  once  or  twice  in  24  hours.  If 
the  serum  is  to  be  kept  for  any  length  of  time,  or  is  to  be  transported, 
he  advises  the  addition  of  less  than  0.5  per  cent  of  phenol.  It  was 
found  that  serum  drawn  24  hours  after  the  first  blood-letting,  had 
always  greater  curative  action  than  the  serum  first  drawn. 

E.  P.  Robinson  was  very  favorably  impressed  with  normal  horse 
serum  as  a  dressing  for  burns,  and  believes  that  its  use  will  eliminate 
the  necessity  for  skin  grafting. 

Shorten,  Cotting  and  Leary,  in  a  very  comprehensive  paper,  re- 
ported excellent  results  with  normal  (beef)  serum  in  the  treatment  of 
wounds.  The  gauze,  soaked  in  serum,  should  come  in  contact  with 
every  portion  of  the  wound  and  should  be  kept  moist.  On  surface 
wounds  the  gauze  may  be  changed  every  4  hours,  or  it  may  be  moistened 
at  intervals  with  the  serum  and  removed  twice  daily.  On  burns  the 
latter  method  was  found  to  be  preferable  and  the  dressings  needed 
changing  only  once  in  24  hours. 

Wounds  of  all  kinds  were  treated.  Skin  grafts  were  covered  with 
perforated  compress  cloth,  over  which  were  placed  3  or  4  layers  of  sterile 
gauze,  soaked  in  the  serum.  This  was  moistened  every  4  hours  with 
the  serum,  and  the  dressing  was  first  removed  on  the  fourth  or  fifth  day. 


l6o  PLASTIC    SURGERY 

The  authors  found  that  the  serum  would  control  sepsis  wherever 
it  came  in  contact  with  the  infected  wound;  that  it  was  harmless  to 
normal  tissue,  and  had  a  prophylactic  value  in  fresh  contaminated 
wounds;  that  the  growth  of  granulation  tissue  was  markedly  stimulated; 
that  when  used  as  a  dressing,  no  matter  how  large  the  wound  surface, 
normal  (beef)  serum  did  not  give  rise  to  anaphylactic  symptoms. 

This  method  of  wound  treatment  has  its  limitations,  for  general 
use,  both  on  account  of  the  difficulty  in  obtaining  large  quantities  of 
the  serum,  and  also  because  of  the  expense.  The  reported  results  are 
most  promising. 

My  own  experience,  limited  to  its  use  as  a  dressing  on  several  wounds 
grafted  with  small  deep  grafts,  proved  very  satisfactory. 

The  Use  of  Soap  in  the  Treatment  of  Wounds 

Before  the  introduction  of  iodin  nearly  every  fresh  lacerated  wound 
was  washed  with  green  soap  and  water  with  satisfactory  results.  Green 
soap  has  been  used  for  many  years  in  the  cleansing  of  chronic  ulcers  by 
thorough  scrubbing  of  the  granulations,  but  this  excellent  method  has 
been  neglected  in  many  clinics.  The  scrubbing  may  be  done  either 
with  a  gauze  pledget,  or  under  a  general  anesthetic  with  a  stiff  brush, 
which  will  also  remove  the  granulations.  Recently  soap  solutions  have 
been  used  in  the  treatment  of  war  wounds.  Dixon  and  Bates  used  a  2.5 
per  cent  sterile  solution  of  common  yellow  soap  in  water,  and  found 
that  dressings  saturated  with  it  did  not  need  to  be  changed  for  three  or 
four  days,  and  that  the  wounds  were  clean  and  healthy  when  the 
dressings  were  removed. 

Haycraft  used  a  i  to  40  solution  of  pure  castile  soap.  Superficial 
wounds  were  excised;  the  soap  solution  was  rubbed  into  the  tissues, 
and  the  wound  was  closed.  Good  results  are  recorded  in  all  the 
reports.  The  dressings  are  said  to  be  painless;  the  solution  is  cheap 
and  easily  obtained. 

The  Two  Route  Methods  of  Treating  Wounds  and  Ulcers 

To  Pfannenstiel  is  due  the  credit  of  introducing  the  method  of 
precipitating  in  a  wound  the  iodin  from  potassium  iodid,  or  sodium 
iodid,  given  internally,  by  bringing  the  surface  of  the  wound  in  contact 
with  dressings  kept  constantly  wet  with  peroxid  of  hydrogen  (3  per 
cent,  acidulated  with  i  per  cent  acetic  acid). 


THE    TREATMENT    OF    WOUXDS  l6l 

The  technic  is  described  by  von  Reuterskiold,  and  is  somewhat  com- 
plicated, but  the  same  result  can  easily  be  obtained  by  the  continuous 
slow  instillation  of  the  peroxid  solution  with  properly  placed  Carrel's 
tubes  (after  adequate  protection  of  the  skin  with  vaselin  or  lanolin) 
and  after  providing  for  necessary  drainage. 

Von  Reuterskiold  divides  the  potassium  iodid  dose  into  four  parts, 
distributed  over  the  day  as  follows:  First  dose  I3;  second  and  third 
doses  If-  each,  and  the  last  }s  of  the  whole  quantity  determined  for 
the  particular  person. 

The  usual  combination  is  as  follows:  3.  grams  of  potassium  iodid  per 
day,  in  doses  as  above  by  mouth.  Continuous  irrigation  of  the  wound 
with  3  per  cent  solution  of  peroxid  of  hydrogen,  acidulated  with  i 
per  cent  acetic  acid.  Doses  proportionately  smaller  than  the  one 
above  act  more  slowly  and  superficially.  After  an  ulcei-  or  wound  has 
become  clean  under  the  full  dosage,  epithelization  and  healing  progress 
more  rapidly  with  smaller  doses. 

The  progress  of  healing  is  still  further  hastened  by  a  skin  graft, 
when  the  following  dosage  should  be  followed :  i .  gram  of  potassium 
iodid,  and  i  per  cent  peroxid  of  hydrogen,  acidulated  with  0.25  per 
cent  acetic  acid. 

When  the  patient  shows  signs  of  gastric  disturbances  due  to  potas- 
sium iodid,  the  same  amount  of  the  drug  may  be  given  per  rectum. 
Von  Reuterskiold  used  the  method  successfully  in  leg  ulcers  (acute  and 
chronic),  infected  wounds  and  for  acute  and  chronic  empyema. 

I  have  had  only  a  limited  experience  with  this  method,  and  am 
unable  to  give  a  definite  opinion  as  to  its  value.  However,  it  seems 
rational  and,  if  properly  carried  out,  might  simplify  the  treatment  of 
certain  selected  cases. 

Massage  and  Passive  Motion  as  Aids  in  the  Treatment  of 

Wounds 

In  the  treatment  of  almost  every  granulating  wound,  healing  may 
be  accelerated  by  systematic  massage  of  the  tissues  surrounding  the 
ulcer,  and  passive  motion  of  the  part  involved.  The  wound  should  be 
treated  by  any  method  deemed  desirable,  and  in  addition,  the  massage 
and  passive  motion  should  be  used  for  the  purpose  of  improving 
circulation  and  loosening  adherent  tissues. 

Cyriax  reports  good  results  following  the  use  of  massage  and  passive 

motion  in  the  treatment  of  septic  war  wounds.     He  says  that  each 
11 


l62 


PLASTIC    SURGERY 


treatment  should  take  from  lo  to  15  minutes,  and  uses  vibration  and 
and  kneeding  (petrissage)  around  the  wound.  The  joints  and  muscles 
are  mobilized  by  passive  and  resisted  movements,  as  well  as  by  active 
movement.  Scar  tissue  should  be  stretched  if  necessary.  As  an 
adjunct  to  other  forms  of  treatment  in  slow  healing  wounds  and  in 
intractable  ulcers,  this  method  should  always  be  borne  in  mind. 

Organic  Coloring  Matters  in  the  Treatment  of  Wounds. 

Anilin  dyes  have  been  used  in  the  treatment  of  wounds  for  two 
purposes:  (i)  For  stimulating  epithelial  growth;  (2)  for  their  antiseptic 
properties. 


Fig.  120. — I.  Varicose  ulcer  of  the  leg,  15X9  cm.  (6  X  3.3/S  inches)  in  a  negro.  2. 
Healed  by  the  use  of  scarlet  red  in  three  months.  This  patient  has  been  under  my  observa- 
tion for  ten  years  since  healing,  and  there  has  been  no  recurrence.  Note  the  invasion  of 
pigment  into  the  newly  healed  area  from  the  edges,  and  in  a  few  isolated  patches.  3.  The 
same  area  taken  three  years  later.  Note  the  greater  encroachment  of  the  pigment  from 
the  edges,  and  the  increase  in  the  size  of  the  patches.  This  area  eventually  became  com- 
pletely pigmented. 

For  the  Stimulating  of  EpitheUum. — Since  Schmieden,  in  1908, 
directed  atitenton  to  the  clinical  use  of  scarlet  red  for  the  stimulation  of 
epithelium  much  work  has  been  done  with  this  dye.  A  careful  study 
of  the  action  of  the  dye  on  a  large  number  of  surface  wounds  has  con- 
vinced me  that  scarlet  red  is  a  very  valuable  epithelial  stimulant,  and 
although  it  will  not  stimulate  epithelial  growth  in  every  case,  it  is  very 


THE    TREATMENT    OF    WOUNDS  163 

helpful  in  the  treatment  of  sluggish  wounds,  if  the  right  dye  is  used  and 
is  properly  applied  (Fig.  120). 

It  is  used  as  an  ointment  (4  to  8  per  cent),  in  vaselin,  balsam  of 
Peru,  or  in  any  other  base  in  which  the  double  effect  is  desired. 

The  most  satisfactory  method  of  applying  the  ointment  is  as  follows: 
Anoint  the  skin  surrounding  the  defect  up  to  within  i  cm.  (%  inch)  of 
the  wound  with  zinc  oxid  ointment,  to  prevent  possible  irritation. 
Apply  the  scarlet  red  ointment,  spread  on  old  linen,  either  along  the 
edges  or  over  the  entire  wound ;  then  cover  with  the  usual  gauze  dress- 
ings and  secure  with  a  bandage.  The  dressing  should  be  changed  every 
24  or  48  hours,  and  alternated  with  some  bland  ointment,  as  irritation 
of  the  skin  may  otherwise  occur.  The  brilliant  red  stain  is  an  objection 
to  its  use,  as  it  is  difficult  to  remove. 

Amidoazotoluol, '  one  of  the  components  of  scarlet  red  (said  to  be  the 
stimulating  ingredient)  is  also  an  excellent  epithelial  stimulant,  and  is 
applied  in  the  same  way.  It  is  used  as  an  ointment  (3.7  per  cent), 
which  is  equivalent  to  the  amount  of  amidoazotoluol  in  an  8  per  cent 
scarlet  red  ointment.  There  is  no  irritation  of  the  skin  and  the  color 
is  not  objectionable. 

Dimazon. — (This  substance  is  used  in  Germany  under  the  name  of 
Pellidol.) 

Dimazon  has  also  given  very  good  results  as  an  epithelial  stimulant. 
I  have  used  it  (2  per  cent  ointment  or  oil)  on  many  wounds  in  the  Out- 
Patient  Department,  and  am  favorably  impressed  with  its  action. 
There  is  no  irritation  of  the  skin,  and  no  staining.  The  technic  of 
application  is  the  same  as  with  scarlet  red  (Fig.  121), 

It  has  been  said  that  in  the  use  of  these  epithelial  stimulants  there  is 
danger  of  producing  malignant  growths,  by  the  over  stimulation  of  epi- 
thelium. In  a  wide  experience  with  these  dyes,  I  have  never  seen  this 
happen,  and  do  not  believe  that  it  is  more  likely  to  occur  than  with  other 
dressings,  if  the  dyes  are  used  intelligently. 

One  must  bear  in  mind  that  malignant  degeneration  may  occur  in 
chronic  ulcers  which  have  never  been  dressed  with  an  epithelial  stimu- 
lant. Hence,  if  such  degeneration  does  occur,  in  a  chronic  ulcer  which 
has  at  some  time  been  dressed  with  one  of  the  dyes,  it  is  obviously 
unfair  to  denounce  the  dressing  as  the  cause  of  the  degeneration. 

All  of  these  substances  may  be  used  in  powder  form  in  the  desired 
strength,  in  any  of  the  usual  powders  (talcum,  stearate  of  zinc,  boric 
acid,  etc.)  as  a  base.     They  may  be  incorporated  in  adhesive  plaster 

1  Davis,  J.  S.     "Anns.  Surg.,"  May,  1911,  703. 


164 


PLASTIC    SURGERY 


or  dissolved  in  paraffin  wax,  in  all  these  combinations  they  have  proved 
their  value  as  epithelial  stimulants,  but  so  far  as  my  observations  go 
they  do  not  exert  any  antiseptic  action. 

For  Antiseptic  Use. — C.  E.  Simon  and  Wood  found  that  an  acid 
dye,  irrespective  of  its  color  (in  the  standard  concentration  of  i  to  100,- 
000  at  least),  is  devoid  of  bactericidal  properties,  whereas  a  basic 
dye,  likewise  irrespective  of  its  color,  may  possess  inhibitory  power. 
Many  of  these  basic  dyes  in  the  laboratory  showed  a  selective  action  for 
certain  bacteria. 

Methylene  blue  has  been  used  for  years  as  an  antiseptic  in  i  to  2 
per  cent  strength. 


Fig.  121. — Chronic  ulcer  of  the  ankle  following  infection.  (P. 29803). — Healed  in  the 
Out-patient  department  by  the  ordinary  methods,  Dimazon  ointment,  2  per  cent.,  being 
the  epithelial  stimulant  used. 


Dahlia  (Basic  fuchsin,  and  methyl  violet),  in  2  per  cent  aqueous 
solution  is  very  useful  in  overcoming  infection  in  superficial  wounds. 
I  have  used  it  extensively,  and  have  had  excellent  results.  The  granu- 
lations are  dried  and  the  dahha  solution  is  painted  on  with  a  cotton 
swab.  The  tissues  are  stained  a  deep  purple  color.  On  abrasions,  a 
single  apphcation  of  2  per  cent  dahlia  is  often  sufficient.  The  granu- 
lations soon  become  dry,  and  the  discharge  scanty.  I  often  use  dahlia 
on  wounds  which  are  to  be  exposed  to  the  sun  or  electric  hght,  or  over 
which  paraffin  wax  is  placed,  and  find  that  the  infection  is  controlled 
more  rapidly,  and  healing  is  hastened. 

This  substance  seems  to  have  the  double  quality  of  a  germicide,  and 


THE    TREATMENT    OF    WOUNDS  165 

of  an  epithelial  stimulant.  1  have  also  used  it  with  satisfaction  in 
2  per  cent  ointment  in  equal  parts  of  lanolin  and  vaselin.  The  action 
of  dahlia  is  selective  for  certain  bacteria. 

Gentian  violet  in  i-iooo  solution  has  been  used  by  Churchman  for 
irrigating  infected  joints,  as  it  has  a  definite  selective  action  on  certain 
bacteria.  I  have  used  gentian  violet  (2  per  cent)  in  ointment  of  equal 
parts  of  lanolin  and  vaselin,  with  success. 

Basic  Fuchsin. — The  germicidal  action  of  basic  fuchsin  (Grubler's 
Fuchsin,  or  Fuchsin  Merck  Medicinal),  was  tested  by  May,  and  later, 
in  conjunction  with  Heidingsfeld,  he  reported  on  its  clinical  action  on 
granulating  wounds.  The  dye  was  used  in  i-iooo  strength,  and  the 
dressings  were  saturated  with  it. 

Chronic  ulcerative  processes  cleared  up  promptly,  and  there  was 
marked  stimulation  of  epithelium  from  the  edges,  and  also  of  granula- 
tion tissue.  Good  results  were  also  obtained  with  the  following  oint- 
ment: Fuchsin  i  part,  petrolatum  5  parts,  and  lanolin  to  100  parts. 

Acriflavine  has  been  used  with  success  in  the  treatment  of  war 
wounds.  The  best  method  is  to  use  i-iooo  strength  in  normal  salt 
solution  for  the  first  dressing,  and  then  1-5000,  and  1-10,000  if  the 
Carrel  method  of  intermittent  instillation  is  used.  Gauze  may  also  be 
saturated  with  it  for  packs  or  for  compresses.  It  is  non-toxic.  It 
prevents  suppuration  and  infection.  The  surrounding  skin  is  not 
irritated. 

Acriflavine  should  be  used  only  as  an  early  dressing,  as  after  the 
first  week  little  advantage  is  gained,  and  the  substance  seems  to  delay, 
the  process  of  repair.  In  the  majority  of  cases  the  wound  is  not  ren- 
dered bacteriologically  sterile. 

Tubby,  Livingston  and  Mackie  have  used  acriflavine  in  a  paste 
with  the  following  formula;  bismuth  carbonate  25  per  cent;  paraffin 
75  per  cent;  acriflavine  0.5  per  cent.  All  necrotic  tissue  is  removed 
and  drainage  is  established.  The  wound  is  then  washed  out  with 
methylated  spirit,  or  with  absolute  alcohol,  and  is  packed  with  the 
paste.  Relief  of  pain,  rapid  diminution  of  infection,  and  improvement 
in  the  condition  of  the  wound  soon  follows. 

The  antiseptic  action  of  acriflavine  has  been  found  more  prompt 
than  that  of  proflavine,  which  is  used  in  the  same  way,  although  the 
latter  is  effective  and  is  easier  and  cheaper  to  make. 

Brilliant  green  has  been  used  with  success  in  the  treatment  of 
war  wounds  in  1-500,  and  i-iooo  strengths.  Hey  has  also  used  this 
dye  as  a  paste,  as  follows:  Boric  acid  11  ounces,  French  chalk  i  ounce, 


1 66  PLASTIC    SURGERY 

liquid  paraffin  8  fluidounces,  brilliant  green  17.5  grains  (that  is  about 
1-500). 

Bonney  and  Browning  have  been  using  a  mixture  of  brilliant  green 
and  crystal  violet  (Hexamethyl- violet)  for  the  last  two  and  a  half  years 
for  sterilizing  the  skin  and  mucous  membranes,  and  are  convinced 
that  it  is  much  superior  to  iodin  for  this  purpose.  The  solution  used 
contains  i  per  cent  of  a  mixture  of  equal  parts  of  brilliant  green  and 
crystal  violet,  dissolved  in  equal  parts  of  water  and  of  rectified  spirit 
(alcohol  containing  16  per  cent  of  water).  The  powder  is  dissolved  in 
the  alcohol,  and  the  water  is  then  added. 

Six  hours  before  operation  the  skin  is  painted  with  the  mixture, 
and  a  compress  saturated  with  it  is  applied,  and  covered  with  a  water- 
proof material.  The  compress  is  removed  on  the  operating  table  and 
no  further  painting  is  done.  The  skin  is  stained  an  intense  violet 
black,  which  persists  for  about  two  weeks.  There  is  no  irritation 
of  skin  or  mucous  membrane.  The  superficial  epithelial  layer  is  per- 
meated with  the  strong  antiseptic,  which  persists  for  some  time.  The 
color  may  be  removed  by  washing  the  surface  with  Eusol  or  hypochlorite 
of  soda  solution. 

I  have  not  yet  had  an  opportunity  to  try  this  method  of  skin  sterili- 
zation, but  the  penetrating  power  of  the  dye  and  the  permanence  of  the 
antiseptic  action,  seem  most  promising. 

BIBLIOGRAPHY 

Abadie,  J.     Autoplastic  in  case  of  grave  deformity  following  burn.     "Arch.  prov.  de  chir." 

Paris,  191 2,  xxi,  240. 
AiMES,  A.     Treatment  of  burns  by  heliotherapy.     "Gaz.  d.  hop."     Paris.,"  1913,  Ixxxvi. 
Heliotherapy  for  War  Wounds.     "Archives  de  Med.  et  de  phar.,  acie  Militar." 

Paris,  May,  1917,  No.  5,  613. 
Alglave,  p.     Chiffon  taffeta  as  dressing  for  wounds  and  burns.     "Pressemed."     Paris, 

1915,  xxiii,  75. 
Anderson,  L.  G.  and  Chambers,  H.     Treatment  of  septic  wounds  with  bismuth  iodo- 

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"Anns.  Surg.,"  Oct.,  1915,  409. 

D.AKiN  &  DuNH.AM.     "Brit.  Med.  Jour.,"  1917,  ii,  641. 
DeWitt,  L.  M.     "Jour.  Infect.  Dis.,"  May,  1914,  Xo.  3. 
Donnelly,  \V.  H.     "J.  A.  M.  A.,"  Feb.  14,  1914,  528. 
Drlmmond  &  McXee.     "Lancet."    London,  Oct.  27,  1917,  640. 

Hey,  W.  H.     "Brit.  Med.  Jour."    London,  Oct.  6,  1917,  445. 
HoFFM.\x,  S.AL-ER  &  McClure.     "Jour.  Infec.  Dis.,"  1916,  xviii,  353. 
Hull  &  Pilcher.     "Brit.  ;Med.  Jour.,"  1918,  172. 

LiG.VT,  P.     "Brit.  Med.  Jour."     London,  Jan.  20,  1917,  78. 

>L\ssi£,  M.     "Lancet."     London,  May  4,  1918,  635. 

^L\Y  &  Heidingsfeld.     "Jour.  Amer.  Med.  Assn.,"  May  31,  1913,  1680. 

Morg.xn,  W.  p.     "Lancet."     London,  Feb.  16,  1918,  256. 

Pearson.  W.     "Lancet."     London,  March  9,  1918,  370. 

RuHRUH,  J.     "Amer.  Jour.  Obst."     Xew  York,  1914,  Lx.x,  296. 

"Amer.  Jour.  Med.  Science,"  May,  1915,  661. 
Russell,  D.  G.     "Jour.  E.xp.  Med.,"  Dec,  1914,  545. 

Sacks,  O.     "Wiener  klin.  Wchnschr."  X'ov.  9,  1911. 

S.A.VERY.  H.  M.     "Brit.  Med.  Jour.,"  Sept.  14,  1918,  283. 

Short,  Arkle  &  King.     "Brit.  Med.  Jour."    London,  Oct.  20,  191 7,  506. 

Simon  &  Wood.     "Proc.  Soc.  Exper.  Biol.  &  Med."     Xew  York,  191 2-13,  x.  176. 

"Amer.  Jour.  Med.  Science,"  Feb.  1914,  247. 

"Amer.  Jour.  Med.  Science,"  April,  1914,  524. 
Stovall  &  X'iCHOLS.     "Jour.  Amer.  Med.  Assn.,"  Ixvi,  1916,  1620. 

Ti-BBY,   .\.   H.   &  LniNGSTON,   G.   R.   &  ;^L\CKIE,   J.  W.     "Lancet,"  London,  Feb.  15, 

1919,  251. 
Turner,  G.  I.     "Russk.  Vracht.,"  191 7,  xvi,  481. 

AValton  &  Feldman.     "Lancet."     London,  Dec.  2;^.  1916,  1043. 
Webb,  C.  H.  S.     "Brit.  Med.  Jour.,"  June  30,  191 7,  870. 


CHAPTER  VIII 

INTRACTABLE  ULCERS  AND  VARICOSE  VENIS 

INTRACTABLE  ULCERS 

For  the  most  part  an  ulcer  that  is  referred  to  the  plastic  surgeon 
is  one  that  has  been  submitted  to  every  ordinary  method  of  treatment, 
without  success.  In  this  group  may  be  included,  and  I  will  con- 
sider in  the  following  order,  chronic  leg  ulcers,  ulcers  in  old  extensive 
scars,  chronic  ulcers  of  the  groin  (probably  chancroidal  in  origin) 
radium  and  x-ray  burns,  burns  from  electricity  and  some  others. 

When  for  some  reason  or  other  the  'radical  treatment  of  the  ulcer 
is  impracticable,  it  may  be  necessary  to  temporize  and  use  methods 
which  will  allow  the  patient  to  continue  his  occupation.  One  or 
other  of  the  methods  already  mentioned  in  the  section  on  the  treatment 
of  granulating  wounds  may  be  used  to  bring  the  ulcer  into  a  healthy 
condition. 

It  is  essential  in  the  care  of  chronic  ulcers  (whatever  the  etiology) 
to  note  certain  points  in  order  to  follow  intelligently  the  progress  made 
in  the  treatment.  For  my  clinic  I  have  had  printed  skeleton  history 
cards  which  are  carefully  filled  in  at  the  first  examination,  additional 
notes  being  made  at  subsequent  visits. 

History  Card 
Mode  of  Onset.    Duration.    Number.    Situation.    Size  in  cm.   Shape. 

Discharge. — Scant;    profuse;    watery;    purulent;    fetid. 

Edges. — Flat;  thickened;  eroded;  undermined.    Tendency  to  heal. 

Floor. — Granulation  tissue;  healthy;  sluggish;  edematous;  exuber- 
ant; slough;  exposure  of  bone. 

Movable  over,  or  adherent  to,  underlying  tissues.  Pain,  over 
entire    ulcer;    localized. 

Surrotmding  Skin. — Normal;  defective  circulation;  scar;  pigmenta- 
tion; infiltration;  loss  of  sensation;  loss  of  hair;  itching. 

Condition  of  Veins.    Edema  of  Part.    Thrombo-phlebitis.— Ty- 
phoid; post-operative;  puerperal.     Number  of  children. 

178 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS  1 79 

Adjacent  lymph  glands.  General  Condition.  Wassermann  Re- 
action.    X-ray  report.    Histological  Examination. 

Painful  Ulcers 

Some  of  the  chronic  ulcers  are  so  painful  that  almost  any  type  of 
dressing  will  cause  great  distress.  It  is  often  possible  to  locate  one  or 
two  painful  points  in  the  ulcer,  which  in  reality  are  exposed  nerve 
endings.  After  these  points  have  been  found,  pure  carbolic  acid, 
applied  for  two  minutes  on  a  small  toothpick  swab  to  the  painful  point, 
without  being  followed  by  alcohol,  will  often  cure  the  pain  permanently. 
Even  when  the  entire  ulcer  is  painful,  pure  carboHc  acid  applied  in  the 
same  manner  over  the  whole  area  will  often  prove  an  efficient  palliative. 
Thorough  division  of  the  nerves  supplying  the  area,  at  points  fairly 
close  to  the  ulcer,  will  effect  permanent  relief  of  the  pain. 

OPERATIVE  TREATMENT 

The  best  method  of  treatment,  and  the  one  which  can  be  applied 
to  all  of  these  ulcers,  is  complete  excision  and  closure,  either  by  skin 
grafting  (immediately  or  later),  or  by  plastic  operation.  The  ordinary 
method  of  procedure  is  to  carbolize  or  cauterize  the  ulcer  thoroughly 
and  then  to  excise  with  a  good  margin  do^^^l  to  normal  tissue,  taking 
care  not  to  open  into  the  granulating  surface  from  below  during  removal. 
Any  type  of  skin  graft  may  be  used  to  cover  these  defects,  but  my  pref- 
erence is  for  small  deep  grafts. 

If  excision  is  not  practicable  radiating  incisions,  including  the 
margins  of  the  w^ound  may  be  made  to  improve  the  circulation,  or  in 
addition  the  base  of  the  ulcer  may  be  criss-crossed  with  incisions  extend- 
ing through  to  normal  tissue.  An  incision  completely  surrounding 
the  ulcer  about  2.5  cm.  (i  inch)  beyond  the  margin  is  often  useful.  The 
results  of  these  methods  are  not  so  good  or  so  rapid  as  those  following 
complete  excision. 

The  Treatment  of  Chronic  Ulcers  by  Nerve  Stretching.- — Smits 
reports  favorable  results  following  nerve  stretching  and  nerve  lacerating 
(by  the  methods  suggested  by  Chipault),  in  the  treatment  of  perforating 
ulcers  of  the  foot,  and  of  certain  varicose  ulcers,  which  he  also  believes 
to  be  trophic  in  origin.  Piccoli  and  Fontana  were  also  successful  with 
this  method  in  treating  perforating  ulcers  of  the  foot.  Veyrassat  and 
Schlesinger  resected  the  S3'mpathetic  nerves  in  the  sheath  of  the  femoral 


t8o 


PLASTIC    SURGERY 


artery  in  Scarpa's  triangle,  and  also  reported  good  results  in  perforating 
ulcer  of  the  foot.  The  same  method  has  been  used  in  the  treatment  of 
ulcers  in  other  parts  of  the  body  (Fig.  122). 

Nerve  stretching  or  laceration  was  done  only  in  cases  in  which  the 
ordinary  methods  of  treatment  had  failed.  In  addition  to  the  nerve 
stretching,  the  ulcer  was  excised  and  the  defect  closed  by  plastic  opera- 
tion or  skin  grafting.  Varicose  veins  were  also  dealt  with  by  surgical 
methods. 


Fig.  122. — Trophic  ulcer  of  the  foot. — An  ulcer  of  this  type  is  difficult  to  heal.  Rest 
in  bed,  constitutional  and  local  treatment  being  the  best  preliminary  steps.  Later  if 
conditions  are  favorable,  nerve  stretching  with  grafting  of  the  granulating  surface,  or 
excision  and  the  implantation  of  a  pedunculated  flap. 


In  the  perforating  ulcers  of  the  foot,  in  various  cases  the  following 
nerves  were  either  stretched  or  lacerated:  the  external  saphenous,  the 
posterior  tibial,  the  musculo  cutaneous,  the  plantar,  the  external  pop- 
liteal, and  the  sciatic. 

In  varicose  ulcers  the  following  nerves  were  either  stretched  or 
lacerated:  the  internal  saphenous,  the  external  saphenous,  the  external 
popliteal,  and  the  sciatic. 

I  have  had  no  experience  with  this  method,  but  it  seems  rational, 
especially  for  trophic  ulcers.     The  radical  operative  procedures  used 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS  l8l 

in  conjunction  with  the  nerve  stretching  may  have  a  good  deal  to  do 
with  the  favorable  results. 


Treatment  with  X-ray  or  Radium 

I  have  had  no  personal  experience  with  the  .r-ray  or  radium  treat- 
ment of  chronic  ulcers,  although  good  results  are  reported.  Neverthe- 
less, manv  ulcers  have  been  referred  to  me  after  having  been  submitted 
to  such  treatments  without  benefit,  and  in  some  of  these  the  problem 
has  been  complicated  by  burns  due  to  the  radiation. 

Etiology  of  Chronic  Leg  Ulcers 

In  a  large  majority  of  these  ulcers  it  is  impossible  to  decide  upon  the 
etiology.     Many  of  them  are  punched  out  and  have  the  clinical  char- 


FiG.  123. — Typical  varicose  ulcer  of  the  leg  of  long  standing. — Note  the  sluggish  appear- 
ance of  the  ulcer  itself  and  the  involvement  of  the  surrounding  skin  with  scar  tissue.  A 
large  varicose  vein  can  be  seen  between  the  ulcer  and  the  left  hand  margin  of  the  photograph. 
It  is  useless  to  attempt  a  permanent  cure  in  a  case  of  this  type  unless  the  veins  are  excised. 

acteristics  of  luetic  ulcers,  but  no  spirochetes  can  be  found,  and  the 
Wassermann  test  is  negative;  while  in  others,  which  are  clinically  of 
the  varicose  type,  the  Wassermann  test  is  positive  and  healing  is  accel- 
erated by  the  proper  systemic  treatment. 

Again,  the  veins,  which  are  not  visibly  or  palpably  varicosed,  are 
found  at  operation  to  be  much  enlarged,  and  healing  follows  the  proper 
operative  procedure.     In  some  of  this  group  syphilis  is  also  present, 


l82 


PLASTIC    SURGERY 


hence  it  is  often  most  difficult  to  determine  which  condition  is  primarily- 
accountable  for  the  lesion  (Figs.  123  and  124). 

The  majority  of  chronic  ulcers  are  situated  on  the  leg,  but  in  spite 
of  their  great  number  and  the  extreme  chronicity  of  many  of  them, 
it  is  remarkable  that  malignant  degeneration  is  so  infrequent. 

NON-OPERATIVE  TREATMENT 

In  the  non-operative  treatment  of  any 
ulcer  of  the  leg,  rest  and  support  are  of 
L^reat  importance.  In  many  instances  the 
patient  cannot  afford  to  lay  up,  and  we 
have  to  depend  entirely  upon  support  of 
the  part.  This  may  be  obtained:  (i)  By 
-trapping  with  adhesive  plaster,  or  ban- 
daging with  a  rubber  bandage.  (2)  By 
bandaging  with  muslin,  flannel,  or  woven 
bandages.  (3)  With  a  gelatin  cast.  (4) 
With  a  canvas  or  elastic  stocking. 

Adhesive  Plaster  Support. — I  once 
heard  the  Professor  of  Surgery  in  one  of 
the  Medical  Schools  say  during  the  dis- 
cussion of  a  paper  on  the  treatment  of 
ulcers,  that  he  had  never  seen  a  leg  ulcer 
which  he  could  not  cure  in  six  weeks  by 
strapping  it  with  adhesive  plaster.  Un- 
fortunately, this  has  not  been  my  own 
experience  nor  apparently  that  of  many 
others,  for  I  constantly  see  leg  ulcers 
which  have  been  under  treatment  for 
many  years,  and  which  from  time  to  time  have  been  systematically 
strapped  with  adhesive  plaster  without  material  benefit.  As  a  matter 
of  fact  these  old  ulcers  are  extremely  difficult  to  cure,  even  when  sub- 
mitted to  the  most  radical  measures. 

I  seldom  use  adhesive  plaster  for  strapping  an  ulcer  for  the  purpose 
of  support,  but  often  employ  it  as  a  dressing.  In  strapping  a  leg  prop- 
erly for  support,  the  adhesive  plaster  should  extend  from  the  base  of  the 
toes  to  just  below  the  knee.  If  the  ulcer  is  discharging,  the  strapping 
must  be  changed  at  least  once  in  48  hours.  The  method  is  expensive 
and  has  little  advantage  over  the  bandage.     If  adhesive  is  used  for 


Pig.  124. —  Luetic  ulcers. 
Many  months  duration. — These 
ulcers  were  healed  by  the  intra- 
venous use  of  salvarsan  in  conjunc-- 
tion  with  proper  local  treatment. 


INTRACTABLE    ULCERS    AND    VARICOSE    VEINS 


I«3 


strapping,  the  strips  should  be  about  2.5  cm.  (i  inch)  wide,  and  7.5 
or  10.  cm.  (3  or  4  inches)  longer  than  the  circumference  of  the  part.  One 
should  start  at  the  root  of  the  toes,  as  should  be  done  for  all  supporting 
bandages,  and  gradually  work  up,  placing  the  center  of  the  plaster 
strip  on  the  part  opposite  the  ulcer  and  drawing  the  ends  over  it. 

Martin's  Rubber  Bandage. — A  thin  bandage  of  pure  rubber,  from 
6.25  to  7.5  cm.  (239  to  3  inches)  wide,  as  suggested  by  ^Martin,  is  also 
used  for  bandaging  such  cases,  and,  after  the  initial  cost,  has  the  advant- 
age of  economy,  because  it  can  be  easily  washed.  Although  it  provides 
good  elastic  support  I  do  not  advise  this  bandage,  as  it  is  difficult  to 
keep  the  skin  in  good  condition  beneath  it. 

Pressure  Bandage.^ — The  bandage  ordinarily  used  for  pressure  is 
made  of  muslin.     It  should  be  5. cm.  (2  inches!  wide  for  the  foot  and 


Pig.  125. — Method  of  applying  a  smooth  even  pressure  bandage  to  the  leg. — After 
applying  the  ordinary  figure-of-eight  bandage  to  the  foot  and  ankle,  follow  the  contour 
of  the  leg  upward,  keeping  both  edges  of  the  bandage  fiat  against  the  leg  as  described  in 
the  text,  and  as  shown  in  the  photographs. 


ankle,  and  from  6.25  to  7.5  cm.  (I'^o  to  3  inches)  for  the  leg.  If  wider 
bandages  are  used  a  well  fitting  support  cannot  be  obtained.  Probably 
no  type  of  bandage  is  poorly  applied  so  often  as  a  pressure  bandage 
of  the  leg.  For  some  years  I  have  used  with  satisfaction  the  figure- 
of-eight  bandage  with  long  sweeps,  fitting  it  accurately  and  following 

^  Davis,  J.  S.,  "Johns  Hopkins  Hospital  Bull.,"  April,  190S,  114. 


1 84 


PLASTIC    SURGERY 


the  contour  of  the  leg.     It  is  comfortable,  firm,  gives  an  even  pressure 
and,  if  properly  applied,  will  remain  in  place. 

Method  of  Application. — Elevate  the  leg,  sponge  the  skin  with 
alcohol,  dress  the  ulcer  in  any  way  desired,  and  sprinkle  the  skin  with 
dusting  powder.  Cover  the  area  to  be  bandaged  with  glazed  cotton 
or  a  thin  layer  of  gauze,  being  sure  that  the  entire  dressing  is  smooth. 
Over  this,  with  a  5.  cm.  (2  inch)  muslin  bandage,  take  a  loose  turn 
around  the  ankle  then  using  an  ordinary  snugly  fitting  figure-of-eight 
pattern,  bandage  the  foot  and  ankle  from  the  root  of  the  toes.     Follow 


Fig.  126. — Method  of  applying  a  pressure  bandage  continued. — The  same  procedure 
is  followed  with  shorter  sweeps  as  we  approach  the  upper  portion  of  the  leg  as  the  pattern 
gradually  develops.  There  is  no  reverse  necessary  anywhere  during  the  application  of  this 
type  of  bandage. 


the  contour  of  the  leg  upward  to  the  level  of  the  tubercle  of  the  tibia, 
taking  care  that  both  edges  of  the  bandage  everywhere  lie  fiat  against 
the  leg.  Then  after  a  circular  turn,  and  using  a  6.25  or  7.5  cm.  (23^^ 
or  3  inch)  bandage,  come  down  the  leg  with  a  long  sweep,  always  keeping 
both  edges  flat,  and  gradually  fill  in  the  uncovered  portions.  The 
pattern  develops  as  this  procedure  is  carried  on,  terminating  in  one  or 
more  circular  turns.  The  end  of  the  bandage  is  secured  with  a  strip 
of  adhesive  plaster  (Figs.  125  and  126). 

Flannel  bandages  made  of  strips  of  flannel  cut  on  the  bias  are  of 
use  where  elastic  pressure  is  needed.     Several  excellent  woven  bandages 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS  1 85 

are  on  the  market  in  which  there  are  no  incorporated  rubber  strips. 
These  have  the  advantage  of  being  very  elastic  and  are  washable. 

Bandages  can  be  used  in  all  stages  of  the  treatment,  and  when  the  ulcer 
is  foul  and  the  discharge  profuse,  it  is  the  rational  method  of  support. 

The  Gelatin  Cast  (Unna's  Paste). — Splendid  smooth  support  can  be 
obtained  with  the  flexible  gelatin  cast,  which  was  first  used  by  Unna. 
The  process  of  application  is  as  follows:  After  a  small,  fiat  dressing 
has  been  applied  to  the  ulcer,  the  foot  and  leg  are  covered  with  one  or 
two  layers  of  gauze  bandage  (preferably  by  the  method  described  for 
the  pressure  bandage).  Then  this  bandage  is  saturated  with  a  mixture 
of  gelatin  lo  parts,  zinc  oxid  10  parts,  glycerin  25  parts,  and  water 
50  parts,  which  is  melted  in  a  double  boiler  and  applied  with  a  brush. ^ 
A  number  of  similar  combinations  have  been  used,  all  of  which  are 
satisfactory.  In  the  application  care  should  be  taken  that  the  mixture 
is  not  too  hot.  Another  layer  of  gauze  bandage  is  then  applied,  over 
which  is  painted  a  second  layer  of  the  gelatin  paste.  This  is  repeated 
until  4  or  5  layers  have  been  applied.  Then  a  layer  of  split  glazed  cotton 
(with  the  glazed  side  out)  is  applied  over  the  cast  to  prevent  any  stick- 
ing to  the  clothes.  Drying  of  the  cast  can  be  much  hastened  by  a 
douche  of  cold  air. 

These  casts  fit  perfectly  and,  w^hen  the  ulcer  is  nearly  healed,  may 
be  left  on  for  two  or  three  weeks,  the  skin  being  kept  moist  and  in  good 
condition.  In  hot  weather,  however,  they  are  not  so  convenient.  Until 
the  ulcer  is  clean,  and  the  discharge  is  scant,  the  cast  should  be  changed 
every  day,  because,  even  if  a  window  is  cut  over  the  ulcer,  the  secre- 
tions will  still  run  down  between  the  cast  and  the  skin.  In  selected 
cases,  and  during  certain  stages  of  treatment,  this  bandage  is  an  ideal 
method  of  support. 

The  Canvas  Legging  and  Elastic  Stocking. — The  canvas  legging, 
first  described  by  J.  B.  Murphy,  is  an  excellent  support  after  healing  is 
complete.  Murphy's  legging  does  not  include  the  ankle  or  foot. 
After  healing  is  complete  and  the  patient  is  left  to  his  own  resources,  I 
have  been  using  with  good  results  a  laced  canvas  stocking  which  can  be 
loosened  or  snugged  at  will.  It  includes  the  foot  from  the  base  of  the 
toes  (omitting  the  heel).  These  stockings  are  washable  and  quite 
durable. 

Elastic  Stocking. — The  woven  rubber  elastic  stocking  so  commonly 
used  for  supporting  purposes  is  very  satisfactory  as  long  as  the  stocking 

^  The  original  Unna's  paste  was  a  mixture  of  gelatin  4  parts,  zinc  oxid  4  parts,  gljxerin 
10  parts,  water  10  parts. 


1 86 


PLASTIC    SURGERY 


is  new.  But  as  soon  as  the  rubber  begins  to  deteriorate,  the  stocking 
becomes  loose,  the  element  of  support  is  lost,  and  the  patient  who 
continues  to  wear  it  may  unconsciously  do  himself  a  good  deal  of  harm. 
The  objections  to  the  elastic  stocking  are  threefold:  (i)  It  soon  loses 
its  supporting  power;  (2)  It  cannot  be  washed;  (3)  It  is  too  expensive 
except  for  the  few. 

I  advise  some  of  my  patients,  with  much  scar  tissue  on  the  leg  and 
with  occupations  in  which  injury  is  probable,  to  use  a  small  football 


Pig.  127. — Bilateral  varicose  veins  of  the  lower  extremities.  Duration,  many  years. 
The  involvement  of  the  right  leg  in  this  case  was  more  marked.  There  was  no  history  of  a 
thrombophlebitis.  The  patient  suffered  little  inconvenience,  and  came  in  for  another 
trouble.  There  had  been  several  superficial  ulcers  during  the  preceding  years,  but  they 
had  healed  promptly. 

shin  guard,  such  as  is  furnished  in  athletic  stores  for  boys.  Protect- 
ors of  metal  or  of  felt  have  been  suggested,  and  some  of  my  patients 
have  made  very  satisfactory  ones  for  themselves. 

VARICOSE  VEINS 

Many  ulcers  of  the  leg  are  primarily  due  to  varicose  veins;  others, 
which  have  resulted  from  other  lesions,  are  prevented  from  healing  by 
the  impairment  of  circulation  due  to  varicosities.  Often,  after  the 
defective  veins  have  been  properly  treated  the  ulcers  will  heal  promptly 
and  there  will  be  no  recurrence  (Fig.  127). 


INTRACTABLE   ULCERS   AND  VARICOSE  VEINS 

OPERATIVE  TREATMENT 


187 


Operative  treatment  of  the  veins  is  essential,  if  permanent  relief  is 
desired. 

Four  methods  will  be  mentioned: 

I .  Excision  of  portions  of  the  veins,  between  ligatures  with  closure 
of  the  skin,  as  typified  by  Trendelenburg's  operation. 


Fig.  128.  Fig.   129. 

Fig.  128.- — Friedel's  operation  for  varicose  veins  with  extensive  scar  tissue  involvement 
(Binnie).  The  long  saphenous  vein  is  ligated  and  divided  high  up  on  the  thigh.  The 
spiral  incision,  the  loops  of  which  may  be  quite  close  or  fairly  far  apart,  extends  from  the 
ankle  to  just  above  the  knee  and  penetrates  down  to  the  deep  fascia.  All  bleeding  vessels 
are  ligated.  Where  an  ulcer  exists  the  spirals  should  surround  the  leg  above  and  below  it, 
and  in  addition  the  spirals  should  be  joined  by  two  vertical  incisions  to  isolate  the  ulcer. 
The  whole  length  of  the  wound  should  be  packed  and  allowed  to  heal  by  granulation,  care 
being  taken  to  destroy  the  superficial  granulations  so  that  the  epithelium  will  finally  cover 
a  spiral  gutter. 

Fig.   129. — The  appearance  of  the  leg  after  healing  is  complete. 

2.  Circular  or  spiral  incisions,  encircling  the  leg  down  to  the  deep 
fascia,  with  division  and  ligature  of  all  vessels,  without  closure  of  the 
skin.  The  edges  are  kept  apart  with  packing,  and  deep  scars 
result,  which  permanently  break  the  continuity  of  the  vessels.  This 
method  is  typified  by  the  operations  of  Schede,  Friedel,  and  others 
(Figs.  128  and  129). 


PLASTIC    SURGERY 


Fig.  130. — Scar  following  complete  excision  of  the  internal  saphenous  vein  for  varicose 
veins. — The  scar  extends  from  the  saphenous  opening  to  the  internal  malleolus.  The  vein 
is  tied  on  both  sides  at  the  opening.  The  tissues  are  then  turned  back  as  far  as  necessary 
on  each  side  of  the  incision  and  all  diseased  veins  are  removed.  In  old  cases  the  skin  may 
be  friable  at  the  site  of  healed  ulcers,  and  slight  separation  of  the  edges  may  occur,  as  in 
this  case.      This  operation,  while  it  is  the  most  radical,  is  by  far  the  most  effective. 


Fig.  131. — C.  H.  Mayo's  vein  stripping  operation  for  varicose  veins  (Binnie). 
Expose  and  isolate  the  internal  saphenous  vein  near  the  saphenous  opening.  Divide  it 
between  ligatures.  Pass  the  peripheral  end  of  the  vein  through  the  loop  in  Mayo's 
dissector  (a).  Following  the  vein,  push  the  dissector  down  to  a  point  near  the  knee;  cut 
through  the  skin  over  the  loop  of  the  dissector;  clamp  the  vein  peripherally,  pull  it  out, 
ligate,  and  remove  the  loose  portion.  If  adhesions  around  the  vein  prevent  the  stripping, 
pass  the  closed  lung  forceps  ib)  along  side  of  the  stripper,  and  then  by  opening  the  blades 
the  adhesions  may  often  be  separated.  In  the  same  manner  continue  to  remove  as  many 
veins  as  necessary,  always  working  from  above  downward  in  order  to  avoid  detaching 
thrombi  and  throwing  them  into  the  circulation. 


INTRACTABLE    ULCERS    AND  VARICOSE   VEINS  1 89 

3.  Complete  excision  of  the  internal  saphenous  system  of  veins, 
as  typified  by  the  operations  of  ]\Iadelung  and  others  (Fig.  130). 

4.  The  subcutaneous  dissection,  after  division  of  the  vein  high 
up  between  two  hgatures,  which  is  carried  out  by  means  of  a  vein 
stripper,  era  long  clamp,  as  typified  by  the  operation  of  Mayo  (Fig.  131). 

The  greatest  percentage  of  cures  is  obtained  by  complete  excision, 
but  this  operation  is  a  very  extensive  one  and  is  seldom  done. 

A  combination  of  the  methods  mentioned  may  often  be  advised 
to  suit  a  particular  case. 

The  chief  danger  after  operations  for  varicose  veins  lies  in  a  resulting 
thrombosis  or  embolism.  Fortunately,  such  an  accident  is  relatively 
rare. 

Everything  else  being  equal  operative  procedures  on  varicose  veins 
should  be  deferred  until  after  the  ulcer  has  completely  healed.  Never- 
theless, they  are  sometimes  justifiable  before  healing  is  complete,  pro- 
vided only  that  the  ulcer  has  been  sterilized. 

It  must  be  insisted  that  when  any  operation  is  done  on  the  veins, 
the  patient  should  be  kept  in  bed  with  the  leg' elevated  for  at  least 
three  weeks.  When  he  is  ready  to  get  up  a  snug  bandage  or  stocking 
should  be  applied  before  the  foot  is  lowered;  this  should  be  worn  when 
the  patient  is  up  and  about  for  several  months,  after  which  it  may 
gradually  be  discontinued. 

Skin  Grafts  in  the  Ambulatory  Treatment  of  Ulcers 

In  the  out-patient  department  of  every  surgical  clinic  there  is  a 
large.  I  am  almost  tempted  to  say  a  preponderating,  number  of  persons 
afliicted  with  ulcers  of  varying  etiology,  many  of  them  of  long  standing. 

When  the  unsatisfactory  results  ordinarily  obtained  in  the  treat- 
ment of  these  patients  is  taken  into  consideration,  one  cannot  fail  to 
appreciate  the  enormous  economic  waste  to  the  hospital  in  time  and 
material.  The  wage-earning  capacity  of  the  patient  is  nearly  always 
lowered,  and  in  some  instances  completely  lost. 

It  has  always  been  taught  that  the  first  essential  for  success  in  skin 
transplantation  is  absolute  rest,  with  immobilization  of  the  part 
grafted.  I  fully  agree  with  this  principle  as  the  ideal  procedure,  and 
believe  that  it  should  always  be  carried  out  when  feasible.  Skin  grafts, 
as  ordinarily  used  in  hospitals  on  clean  wounds,  with  the  patient  in 
bed  and  having  the  maximum  of  good  food,  good  nursing,  cleanliness, 
fresh  air,  and  above  all  complete  rest,  is  a  simple  matter.     On  the  other 


I  go  PLASTIC    SURGERY 

hand,  let  us  consider  the  patients  who  come  to  the  out-patient  depart- 
ment. They  are  usually  poorly  nourished,  the  houses  in  which  they 
live  are  often  overcrowded,  and  insanitary.  They  are,  as  a  rule,  unable 
to  stop  their  work,  except  for  the  time  spent  at  the  clinic.  Many  of 
them  should  be  in  the  hospital,  but  there  is  little  chance  for  even  the 
few  who  desire  such  admission  to  secure  beds.  In  short,  rest,  the  factor 
of  greatest  importance  in  the  treatment  of  these  cases,  has  to  be  entirely 
eliminated. 

With  all  these  unfavorable  conditions  in  mind,  I  gradually  prepared 
in  the  out-patient  department  of  the  Johns  Hopkins  Hospital,  a  series 
of  cases  with  the  idea  of  trying  my  luck  with  skin  grafting.  To  my 
surprise  the  first  case  grafted  (that  of  a  long-standing  varicose  ulcer) 
was  a  complete  success,  and  this  success  stimulated  me  to  further  trials. 

In  a  paper ^  written  several  years  ago  I  reported  the  results  in  the 
use  of  skin  grafts  in  the  ambulatory  treatment  of  50  ulcer  cases  of  vary- 
ing etiology,  which  might  be  summarized  as  follows: 

Duration,  a  few  days  to  25  years.  Size,  the  largest,  S.Xiy.cm. 
(3^X6^^  inches);  the  smallest,  1.5 X  1.5  cm.  {%y.%  inch). 

Treatment. — Small  deep  grafts  were  used  on  48^  Olher-Thiersch 
grafts  on  i;  whole-thickness  grafts  on  i.  Result,  well,  36;  improved,  9; 
unimproved,  5.  Of  those  wounds  which  were  improved  by  grafting, 
but  not  completely  healed,  5  were  situated  on  the  foot,  and  4  on  the  leg. 
Of  those  which  were  unimproved,  2  were  on  the  leg,  2  on  the  foot,  and  i 
on  the  chest  wall.  All  of  the  grafts  were  autografts,  and  were  placed  on 
undisturbed  granulations.  Small  deep  grafts  were  used  on  most  of  the 
wounds,  as  the  operative  procedure  is  simple  and  furthermore,  no  other 
type  of  graft  could  have  been  successful  on  many  of  the  lesions. 

It  is  obvious  that  when  the  grafts  are  in  place  they  must  be  secured 
so  that  no  sliding  motion  is  possible.  This  is  easily  done  by  applying 
overlapping  strips  of  rubber  protective,  or  a  sheet  of  paraffined  mesh 
over  the  grafts,  and  then  securing  this  and  the  overlying  gauze  dressing 
with  numerous  strips  of  perforated  adhesive  plaster.  Over  this  is 
placed  more  gauze,  a  snug  gauze  bandage  and,  finally,  a  muslin  or  crino- 
line bandage.  Sometimes  thin  strips  of  splint  wood  were  incorporated 
in  the  dressings.  During  the  duration  of  the  treatment  every  patient 
in  this  series  had  continued  his  or  her  daily  occupation.  In  some  in- 
stances in  which  the  grafts  were  placed  close  together,  the  ulcers  were 
covered  with  epithelium  within  a  week.  When  a  partial  grafting  was 
done,  or  when  only  a  portion  of  the  grafts  were  successful,  a  second 

1  Davis,  J.  S.:  "Jour.  Amer.  Med.  Assn.,"  Feb.  13,  1915,  559. 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS 


191 


Fig.  132. — Varicose  ulcer  of  leg.  Duration  twelve  years,  i.  Before  grafting.  Ambu- 
atory  method.  2.  One  week  after  grafting  with  small  deep  grafts.  3.  Five  months  after 
grafting.  Examination  of  the  patient  five  years  after  grafting  showed  no  tendency  to 
recurrence.     The  healing  was  stable  and  the  individual  grafts  were  still  plainly  visible. 


Fig.  133. — Ulcer'of  the  leg  following  an  infection.  Duration  six  weeks.  Healed  by 
small  deep  grafts. — i.  Before  grafting.  2.  Six  weeks  after  grafting.  The  ambulatory 
treatment  was  used  in  this  case  and  the  patient  continued  his  occupation,  only  returning 
to  the  hospital  for  dressings. 


192 


PLASTIC    SCEGERY 


grafting  was  required  to  fill  the  areas  not  covered.  In  every  case  that 
failed  several  graftings  were  done  but  without  result.  That  several  of 
these  wounds  were  subsequently  grafted  in  the  hospital  wdthout  success, 
would  warrant  the  presumption  that  our  failure  was  due  to  the  ulcer 
itself,  rather  than  to  the  fact  that  the  patient  was  not  kept  at  rest. 

I  feel  confident  that  the  percentage  of  takes  would  have  been  con- 
siderably larger,  had  situation,  etiology  and  other  points  been  carefully 
considered  in  our  selection  of  cases  for  this  series,  but  in  order  to  test 
the  procedure,  ulcers  in  many  situations  and  of  varying  etiology  were 
grafted.  As  might  be  expected,  the  ulcers  on  the  feet  and  legs  were 
more  dithcult  to  heal  than  those  in  other  situations,  and  the  failures 
were  confined  almost  entirely  to  those  regions. 

I  have  been  able  to  observe  some  of  these  patients  for  four  years 
after  grafting,  and  there  has  been  no  recurrence  in  a  single  instance  in 


123  4 

Fig.  134. — Cliromc  ulcer  of  the  leg  due  to  an  acid  burn.  Duration  nine  months. 
(F. 21878.) — I  and  3.  Show  the  ulcer  on  the  outer  and  inner  sides  of  the  leg  joined  by  a 
narrow  unhealed  area.  These  ulcers  were  healed  with  small  deep  grafts  and  the  patient 
was  allowed  to  continue  his  work  in  a  foundry  during  the  treatment.  2  and  4.  The  same 
areas  six  months  after  grafting. 

an  area  successfully  grafted.  In  one  or  two  patients,  with  marked  vari- 
cose veins,  small  ulcers  on  other  portions  of  the  leg  have  occurred,  but 
not  in  the  grafted  area. 

From  these  and  other  results  in  which  grafts  were  used  in  the 
ambulatory  treatment  of  ulcers,  I  feel  that  we  have  added  to  our  arma- 
mentarium a  method  of  procedure  which  has  hitherto  been  used  only 
on  patients  resident  in  the  hospital.  In  other  words,  the  successful 
use  of  grafts  in  the  out-patient  department  will  not  only  make  for  hos- 
pital economy,  but  will  also  hasten  the  return  of  many  patients  to  full 
wage-earning  capacity  (Figs.  132,  133  and  134). 


Ulcers  in  Old  Scars 

Not  infrequently,  especially  after  extensive  burns,  we  find  chronic 
ulcers  situated  in  the  midst  of  scars  which  resist  all  the  usual  methods 


INTRACTABLE    ULCERS    AND    VARICOSE    VEINS 


193 


of  wound  treatment.  The  cause  of  this  resistance  to  heaUng  is  to  be 
looked  for  in  poor  circulation,  due  to  dense  surrounding  and  underlying 
scar  tissue.  It  is  in  just  such  ulcers  that  malignant  degeneration 
occasionally  occurs.  In  these  obstinate  cases  we  have  to  resort  to  ex- 
cision down  to  normal  tissue — no  matter  how  extensive  the  excision 
may  be — followed  by  grafting  of  the  defect,  or  shifting  in  pedunculated 
flaps  (Figs.  135-138). 


Fig.  135. — Chronic  ulcer  in  the  midst  of  a  dense  thickened  scar,  following  a  burn. 
Duration  fourteen  months. — i.  The  condition  of  the  ulcer.  2.  Three  weeks  after  grafting 
with  small  deep  grafts.  There  has  been  no  recurrence  during  the  ten  years  since  grafting. 
In  this  case  the  ulcer  might  have  been  e.xcised  down  to  normal  tissue  and  the  area  grafted, 
but  complete  excision  of  the  entire  thickened  scar  was  impossible  on  account  of  its  extent. 


Chronic  Ulcers  in  the  Groin 

Another  type  of  chronic  ulcer  which  has  given  me  much  trouble  is 
that  which  follows  a  (probably)  chancroidal  infection.  Such  ulcers  are 
very  difficult  to  heal  and  in  spite  of  all  our  efforts  are  liable  to  spread. 

Excision  with  the  cautery  is  the  safest,  and  in  the  long  run  the  most 
rapid  method  of  procedure,  although  it  seems  so  radical  that  one  sel- 
dom has  the  courage  to  resort  to  it  until  every  other  method  has  been 
tried.  In  some  cases  I  have  used  the  cautery  repeatedly  to  check  the 
spread  of  such  an  ulcer,  and  as  soon  as  the  slough  had  separated  and 
the  granulations  were  healthy  applied  a  few  skin  grafts  and  thus  gained 


194 


PLASTIC    SURGERY 


a  short  distance.     This  procedure  was  then  repeated  once  or  several 
times  until  finally  the  infection  was  eliminated  (Fig.  139).' 

I  have  had  no  help  from  the  x-ray  or  radium  in  the  treatment  of 
these  ulcers. 


Pig.  136. — Ulcer  of  the  ankle  following  a  streptococcus  infection.  Photograph  taken 
after  the  excision  of  the  surrounding  scar  tissue.  Duration  6  months,  i.  The  wound  was 
completely  healed  in  two  weeks  by  the  use  of  small  deep  grafts.  2.  Taken  two  years  and 
three  months  after  grafting.  There  has  been  no  breakdown  after  more  than  five  years, 
and  the  functional  result  is  perfect. 

X-ray  Bums 

X-ray  burns  were  at  one  time  quite  common  before  the  methods 
of  protecting  patient  and  operator  were  known,  and  when  long  ex- 
posures were  necessary  to  secure  satisfactory  plates.     Today,  they  are 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS 


195 


usually  found  after  treatments  for  skin  diseases,  long  and  frequent 
exposures  in  the  treatment  of  inoperable  carcinoma,  and  from  the  use 
of  the  apparatus  by  unskilled  operators.  It  is  generally  thought  that 
such  burns  are  rare,  but  I  have  seen  a  great  many  of  them,  and  have 
found  them  difficult  to  treat.  Quite  recently  I  had  in  the  hospital  at 
one  time  an  .a;-ray  ulcer  of  the  hand;  one  of  the  ankle,  and  one  of  the 
sole  of  the  foot. 


Fig.  137. — Intractable  ulcer  of  the  sole  of  the  foot  following  frost-bite  in  a  negro  aged 
85  years.  Duration  8  years.  (F.1564.) — The  only  method  of  treating  an  ulcer  in  such  a 
situation  with  any  hope  of  a  permanent  functional  result  is  by  excision  of  the  ulcer 
with  its  surrounding  scar  tissue,  followed  by  the  implantation  of  a  pedunculated  flap. 
The  age  of  this  patient  contraindicated  such  treatment. 


These  ulcers  are  very  chronic,  and  are  usually  exquisitely  sensi- 
tive. This  pain  may  be  relieved  by  division  of  the  nerves  supplying 
the  area  (A.  Eddowes) .  The  surrounding  skin  is  hairless  and  atrophied, 
smooth  and  shiny,  with  or  without  a  blotchy  brownish  pigmentation. 
There  are  characteristic  teliangectases,  which  may  be  discrete  or  occur 
in  reddish  patches.  Punctate  hemorrhages,  due  to  rupture  of  dilated 
capillaries,  are  often  present. 

The  ulcers  may  be  superficial,  or  may  involve  the  full  thickness  of 


196 


PLASTIC    SURGERY 


the  skin,  and  a  considerable  depth  of  the  underlying  soft  parts.  I  have 
seen  the  entire  thickness  of  the  abdominal  wall  implicated  in  a  burn. 

Malignant  degeneration  often  occurs  in  a  chronic  x-ray  burn,  and 
the  lives  of  many  of  the  pioneer  operators  were  lost  in  this  way. 

Treatment. — Recent  x-ray  burns  should  be  treated  as  any  ordinary 
burn.  When  ulcerations  occur  which  do  not  heal  promptly  by  the 
usual  methods,  excision  of  the  ulcer  with  a  wide  margin  and  down  to 


Pig.  138. — Chronic  ulcer  of  the  foot  following  amputation  made  necessary  by  trauma. — 
This  ulcer  is  situated  immediately  over  the  bone,  and  the  surrounding  scar  is  thin  and 
adherent.  The  transplantation  of  a  pedunculated  flap  of  skin  and  fat  is  the  only  chance 
of  securing  a  resistant  painless  healing. 


healthy  tissue  below,  is  our  only  resort.  The  defect  should  be  grafted 
immediately,  if  the  base  of  the  wound  is  of  normal  tissue,  but  if  any 
doubtful  tissue  is  left  in  the  defect  (owing  to  the  impossibility  of  com- 
plete excision)  grafting  should  be  deferred  until  granulations  form.  I 
have  used  pedunculated  flaps  in  several  instances  where  a  soft  pad  of 
tissue  was  necessary. 

In  excising  these  areas  one  is  struck  by  the  resistance  and  rigidity 
of  the  tissues  which  are  sufficient  to  turn  the  edge  of  a  scalpel.  After 
excising  areas  25. cm.  (10  inches)  in  diameter,  I  have  placed  the  tissue 
on  its  edge  and  found  that  it  would  stand  erect  like  a  piece  of  sole 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS 


197 


I  234 

Fig.  139. — Chronic  ulcer  of  the  groin  following  removal  of  the  glands  for  an  infection 
presumably  chancroidal  in  origin.  Duration  three  years. — i.  The  tendency  of  this  ulcer 
was  to  undermine  and  spread.  Condition  when  the  patient  came  under  my  care.  Note 
the  irregular  shape  of  the  ulcer.  2.  Three  months  later.  Note  the  scar  due  to  the  open- 
ing of  the  undermined  portions  with  the  cautery,  and  grafting  when  the  granulations  were 
healthy.  At  this  point  the  ulcer  seemed  under  control;  however,  it  began  to  burrow  again 
in  several  directions  and  it  was  a  year  later  before  the  wound  was  entirely  healed.  3  and  4. 
Taken  one  year  after  2.  Shows  the  scars  in  front  and  behind  which  indicate  the  pro- 
gressive course  of  the  infection.  Bacteriological,  serological  and  microscopic  tests  were 
of  no  avail  in  indicating  the  cause  of  this  infection.  The  use  of  the  cautery  with  grafting  of 
small  areas  as  they  became  healthy  seemed  the  only  method  to  be  depended  upon  in  this 
case,  although  many  others  were  tried. 


Fig.  140.— A'-ray  burn  of  the  ankle.  Duration  two  years. — i.  Note  the  position  of  the 
ulcer  over  the  malleolus.  2.  The  area  was  excised  and  immediately  grafted  with  small  deep 
grafts.  Complete  healing  followed  and  no  breakdown  has  occurred  in  the  two  years 
following  the  operation. 


igS 


PLASTIC    SURGERY 


Pig.  141. — Extensive  X-ray  burn  of  the  abdominal  wall. — This  burn  followed  intensive 
X-ray  therapy  for  an  inoperable  carcinoma  of  the  intestine.  The  pain  was  excruciating. 
The  center  of  the  burn  was  ulcerated  and  this  was  surrounded  by  a  rigid  brown  mass  of 
mummified  tissue.  The  entire  area  was  excised  as  completely  as  possible  and  was  imme- 
diately grafted  with  Ollier-Thiersch  grafts.  Relief  of  pain  and  healing  followed,  although 
the  patient  died  after  several  months  from  carcinomatous  metastases.  In  such  cases 
where  it  is  impossible  to  excise  all  of  the  affected  tissue,  it  is  advisable  to  allow  granula- 
tions to  form  before  the  grafting  is  done. 


Fig.  142. — X-ray  ulcer  and  burn  of  the  wrist  with  contracture  of  the  thumb.  Duration 
ten  years. — i.  The  ulcer  on  the  wrist.  The  dark  line  indicates  the  scar  around  the  ulcer 
which  prevents  flexion  of  the  thumb.  2.  The  ulcer  and  scar  were  excised.  The  surround- 
ing skin  was  shifted  somewhat  and  the  defect  left  was  filled  with  a  whole-thickness  graft. 
Photograph  taken  two  and  a  half  years  after  grafting.  Function  of  the  thumb  is  perfect 
and  the  patient,  who  is  a  farmer,  has  had  no  further  trouble  during  the  ten  years  which 
have  elapsed  since  grafting. 


INTRACTABLE    ULCERS    AND   VARICOSE   VEINS  IQQ 

leather.     Another  noticeable  feature  is  the  difficulty  in  checking  the 
hemorrhage,  which  seems  to  come  from  every  portion  of  the  wound. 

The  use  of  radium  has  been  advised  for  treatment  of  .T-ray  burns. 
Personally,  I  have  seen  quite  a  few  such  cases  in  which  after  this  treat- 
ment no  improvement  was  noted,  but  as  a  matter  of  fact  the  condition 
was  aggravated  (Figs.  140-143). 


I  2  3 

Fig.  143. — Chronic  ulceration  and  keratosis  due  to  constant  exposure  to  X-rays  with- 
out proper  protection. — i.  The  use  of  this  hand  had  been  practically  lost  on  account  of 
painful  ulcerations  and  the  rigidity  of  the  tissues.  2  and  3.  The  fingers  were  amputated 
at  the  first  interphalangeal  joints.  The  ulcerated  area  on  the  dorsum  of  the  hand  was 
excised  and  a  pedunculated  flap  from  the  abdomen  was  implanted.  The  photographs  were 
taken  four  years  after  implantation.  The  flap  has  gradually  assumed  the  level  of  the 
surrounding  skin  and  is  soft  and  movable.  The  movement  of  the  hand  is  as  normal  as  may 
be  without  the  fingers,  and  is  very  useful  to  the  patient.  Five  and  a  half  years  have  elapsed 
since  the  operation,  and  there  has  been  no  tendency  to  malignant  degeneration  on  this  hand. 
The  use  of  the  pedunculated  flap  on  X-ray  burns  of  the  hands  and  feet  is  the  procedure  of 
choice. 

Radium  Bums 

In  its  clinical  appearance  a  radium  burn  is  very  similar  to  an  a;-ray 
burn.  The  treatment  is  practically  the  same,  and  the  same  sort  of 
tissue  change  is  encountered.  I  have  seen  very  extensive  destruction 
due  to  radium  burns,  and  am  sure  that  these  burns  would  be  very  much 
more  numerous  if  the  radium  was  as  easily  obtained  as  an  .v-ray 
apparatus. 

Bums  Due  to  Electricity,  Hot-water-bag  Bums.    Ice-bag  Bums 

Bums  due  to  electricity  may  be  of  the  first,  second  or  third  degree. 
They  differ  from  the  ordinary  burn  in  that  they  present  at  first  a  dry 
charred  appearance,  are  not  so  painful,  but  are  much  more  intractable. 


200 


PLASTIC    SURGERY 


It  is  almost  impossible  at  first  to  determine  how  much  destruction 
has  taken  place.  A  simple  looking  second  degree  burn,  which  would 
give  very  little  trouble  if  caused  by  ordinary  heat,  may  conceal  beneath 


12  3  4 

Pig.  144. — Burn  due  to  electricitj^.  Duration  three  weeks. — i  and  2.  Note  the 
exposed  bones  and  the  great  destruction  of  tissue. — 3  and  4.  After  the  wound  was 
steriUzed  with  Dakin's  solution  the  exposed  bones  were  removed  and  the  metacarpals 
were  covered,  as  far  as  possible,  with  soft  tissue.  All  other  surfaces  were  covered  with 
small  deep  grafts.      Photograph  taken  ten  days  after  grafting. 

the  blister  a  deep  slough.  Where  the  burn  has  been  deep,  the  slough 
assumes  very  much  the  appearance  of  a  dry  gangrene.  After  the  main 
portion  of  the  slough  has  come  away,  further  necrosis  may  occur,  and 


Pig.  145. — Hot  water  ba,g  burn  of  the  heel.  Duration  several  months. — This  ulcer  was 
healed  in  the  Out-patient  department  by  local  treatment,  and  no  recurrence  has  followed 
during  several  years. 


I  have  had  several  cases  in  which  severe  hemorrhage  occurred  either 
just  before  or  just  after  removal  of  the  slough.  The  slough  should  be 
removed  as  soon  as  its  differentiation  is  complete,  and  everything  should 


INTRACTABLE    ULCERS    AND    VARICOSE    VEINS 


20I 


be  done  to  stimulate  granulations  and  the  growth  of  epithelium  from 
the  edges,  as  the  process  of  healing  is  very  slow.  Time  may  be  saved 
by  excision  of  the  entire  area  followed  by  skin  grafting,  or  the  shifting 
in  of  a  pedunculated  flap.  These  burns  are  most  frequently  seen  on 
the  hand,  and  in  many  instances  there  is  complete  loss  of  function  due 
to  contracture,  or  to  the  loss  of  large  portions  of  the  extremity  (Fig. 
144). 

Hot-water-bag  Burns. — Burns  from  hot-water  bags  which  are  in- 
adequately covered,  usually  occur  when  the  bag  is  placed  against  the 
skin  of  a  patient  who  is  unconscious  and  consequently  does  not  feel 


Fig.  146. — Ice  bag  burn.  This  burn  followed  the  long  continued  application  of  an  ice 
bag  on  the  abdominal  wall,  which  was  used  for  the  relief  of  pain  in  pelvic  inflammatory 
disease.  The  destruction  extended  to  the  muscle.  Note  the  extent  of  healing  from  the 
edges  in  three  months.  The  wound  was  healed  promptly  with  small  deep  grafts  by  the 
ambulatory  method. 

pain.  It  is  as  difficult  to  judge  the  degree  of  the  burn  as  in  those  cases 
caused  by  electricity.  There  is  usually  intense  pain,  and  the  healing  is 
extremely  sluggish.  After  trying  many  methods,  I  have  found  that 
where  the  whole  thickness  of  the  skin  is  involved,  excision  and  skin 
grafting  supply  the  only  rational  method  of  treatment.  First  and 
second  degree  burns  should  be  treated  by  the  ordinary  methods 
(Fig.  145). 

Ice-bag  Burns. — The  application  of  an  ice-bag  for  long  periods  to 
the  unprotected  skin  may  cause  lesions  which  are  very  similar  to  hot- 


202  PLASTIC    SURGERY 

water-bag  burns.  The  same  characteristics  are  present,  and  the  treat- 
ment, where  the  full  thickness  of  the  skin  is  destroyed,  consists  in 
excision  and  grafting.  First  and  second  degree  burns  caused  by  an 
ice-bag  should  be  treated  by  the  usual  methods  (Fig.  146). 

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CHAPTER  TX 

SCARS  AND  KELOIDS 

SCARS 

If  he  had  to  deal  only  with  normal  tissue  the  problem  of  the  plastic 
surgeon  would  be  simplified.  As  a  matter  of  fact  however,  the  great 
majority  of  cases  which  come  under  his  care  are  either  due  to  scar  tissue, 
or  are  complicated  by  its  presence.  Scars  may  either  interfere  with  the 
function  of  a  part,  they  may  be  painful,  or  disfiguring,  and  any  one  of 
these  reasons  call  for  the  necessary  treatment. 

Several  types  of  scars  are  encountered,  i.  The  depressed  scar. 
2.  The  extensive  iinstahle  scar.  3.  The  extensive  smooth  scar.  4.  The 
contracted  scar.     5.  The  keloid  and  hypertrophied  scar. 

Depressed  Scars. — Many  excellent  methods  of  dealing  with  de- 
pressed scars  have  been  described  by  Blair,  Esser,  and  others,  and  these 


ex 
<x 
ex 

I  2  3 

Fig.  147. — Method  of    repairing  a  defect  due  to  scar  tissue  (Blair),      i.   The  shaded  area 
indicates  the  tissue  excised.      2.   Sutures  inserted.     3.   Sutures  tied. 

can  be  best  understood  by  reference  to  the  plates.  For  several  years 
I  have  used  the  method  recently  described  by  Poulard  for  the  treatment 
of  depressed  adherent  scar  of  the  face  but  the  credit  of  publication 
belongs  to  him.  I  have  found  it  very  satisfactory,  especially  in  those 
situations  in  which  it  is  difficult  to  shift  in  the  surrounding  tissues 
any  considerable  distance.  Depressed  scars  are  often  adherent  to 
underlying  muscles  and  cause  pain  and  deformity.  Complete  excision 
with  the  transplantation  of  either  a  fat  or  fascia  graft  and  closure  of  the 
skin  should  be  considered  in  these  cases  (Fig.  147-154). 

Unstable  Scars.  ^ — The  treatment  of  tightly  stretched  unstable  scars 
that  frequently  break  down  has  long  been  a  source  of  worry  to  the  sur- 
geon and  distress  to  the  patient.     This  type  of  scar  usually  follows 

1  Davis,  J.  S.  "Jour.  Amer.  Med.  Assn.,"  Dec.  22,  191 7,  Ixix,  2085. 

206 


SCARS    AND    KELOIDS 


207 


extensive  deep  burns,  or  loss  of  tissue  by  trauma,  when  the  wound  has 
been  allowed  to  heal  by  the  slow  process  of  cicatrization,  without  the 
aid  of  skin  grafting  or  of  plastic  operation. 


123  4 

Fig.  148.- — Operation  for  the  correction  of  depressed  and  adherent  scars  (Poulard). — 
I.  The  depressed  adherent  scar.  The  dotted  line  indicates  the  incision  to  be  made  around 
the  scar.  2.  The  retraction  of  surrounding  skin  after  the  incision  is  made.  The  island 
of  scar  tissue.  3.  The  removal  of  the  epithelial  surface  of  the  scar.  4.  The  normal  skin 
closed  over  the  island  of  scar  tissue  after  undercutting. 


/DEPRESSED  SCAR 


Fig.  149. — Method  of  excising  a  depressed  scar  by  means  of  oblique  incisions. — i.  The 
dark  lines  indicate  the  incisions  made  for  excising  the  scar.  These  incisions  make  the 
approximated  surfaces  somewhat  longer  than  if  they  were  made  at  right  angles  to  the  sur- 
face. Thus  the  line  of  closure  is  thicker  than  the  normal  skin  and  allowance  is  thus  made 
for  subsequent  shrinkage.      2.   The  wound  closed. 


DEPRESSED  SCAR 


Fig.  150. — Method  of  using  the  deep  portion  of  a  scar  to  buttress  the  skin. — i.  The 
shaded  area  indicates  the  scar.  The  dark  lines  the  incisions.  2.  The  superficial  portion 
of  the  scar  is  excised  and  the  skin  undercut,  shifted  inward  and  sutured  over  the  undis- 
turbed deeper  portion  of  the  scar. 


The  original  wounds  are   always  large   and   usually  involve   the 
entire  circumference  of  a  part,  such  as  the  leg  or  thigh,  or  occasionally 


208 


PLASTIC    SURGERY 


the  calvarium.     In  other  words,  the  scar  surrounds  and  compresses 
the  part. 

Some  of  the  scars  are  bluish  red  ^-ith  fine  superficial  vessels;  others 
are  pale  and  seem  to  have  little  or  no  blood  supply.     Frequently  there 


Fig.  151. — Methods  of  dealing  with  depressed  scars  (Aymard). — i.  Usual  method  of 
separating  skin  from  fat,  as  shown  by  dotted  Hnes.  The  fat  from  each  side  is  then  drawn 
together  and  held  by  sutures.  2.  Aymard's  method.  The  thick  black  lines  represent  the 
incision  through  the  desired  amount  of  fat.  The  block  of  fat  depends  on  the  skin  flap  for 
its  blood  supply.     3.   Shows  the  fat  flap  rolled  in  and  sutured.      The  skin  is  then  closed. 

are  superficial  ulcers  of  varying  size  scattered  over  the  surface.  The 
scars  are  as  unstable  as  wet  tissue  paper  and  the  slightest  injury  will 
start  an  ulcer  that  -^-ill  require  weeks  to  heal. 


;^H 


Fig.  152. — Depressed  scar  of  the  cheek  following  a  cut. — This  scar  is  directh'  across  all 
the  natural  folds  of  the  face  and  neck,  and  for  that  reason  is  especially  difiicult  to  correct. 
It  is  also  deep  and  the  adjacent  tissue  is  infiltrated  with  scar.  Complete  excision  with  the 
use  of  a  pedicled  narrow  flap  of  subcutaneous  fat  turned  into  the  defect  is  the  method  of 
choice,  with,  of  course,  verj'  careful  adjustment  and  suturing  of  the  skin. 

There  is  little  resistance  to  trauma  or  infection  and  an  area  that  is 
healed  mxay  without  any  apparent  cause,  in  a  very  short  time  break 
down  entirely,  or  multiple  ulcers  may  develop. 


1234 

Fig.  153.— Deep  adherent  scars  of  the  face. — i  and  2.  Before  operation.  3  and  4. 
The  result  of  excision,  turning  over  a  flap  of  subcutaneous  fat  and  suturing.  The  scar  on 
the  right  side  was  much  more  difficult  to  correct  as  it  cut  across  the  natural  folds. 

A  number  of  these  patients  have  come  under  my  care,  and  for  a 
long  time  they  gave  me  much  trouble.  After  I  had  used  many  methods 
with  little  success,  it  occurred  to  me  to  tr\'  relaxation  incisions  and  to 
graft  the  defects  thus  made. 


SCARS    AND    KELOIDS 


209 


Technic. — Preferably  the  area  should  be  entirely  healed  before 
the  incisions  are  made,  but  in  some  instances  when  the  healing  of  the 
superficial  ulcers  has  been  extremely  sluggish,  I  have  not  waited  for 
complete  healing,  but  have  operated  as  soon  as  the  granulations  have 
been  brought  into  a  healthy  condition.  In  preparation  for  operation 
in  the  unhealed  cases,  after  the  granulations  are  healthy,  the  part  is  put 
up  in  a  dressing  kept  wet  with  normal  salt  solution  for  24  hours.  The 
granulations  are  then  painted  with  tincture  of  iodin,  and  the  surround- 
ing scar  is  cleaned  with  ether  and  alcohol. 

In  many  cases  the  relaxation  incisions  can  be  made  after  infiltration 
with  a  local  anesthetic  such  as  Schleich's  solution,  or  0.5  per  cent  novo- 


FiG.  154. — Scars  of  cheek,  eyelids  and  forehead,  following  an  accident  three  months 
previously. — i  and  2.  Show  the  condition  on  admission  to  the  hospital.  The  eyelids 
cannot  be  closed.  3.  Result  of  excision  of  scars  on  the  forehead  and  cheek,  and  of  re- 
adjusting the  lid  margins.     Taken  one  year  after  operation. 


cain.  In  other  instances  a  general  anesthetic  is  advisable,  especially 
if  large  immediate  OlHer-Thiersch  grafts  are  to  be  used  to  cover  the 
defect. 

On  an  arm  or  leg  long  incisions  should  be  made,  parallel  with  the 
long  axis  of  the  part,  down  to  the  deep  fascia;  or  to  healthy  tissue,  if 
the  destruction  has  been  deeper  than  the  fascia.  Three  relaxation 
incisions  are  usually  sufl&cient  for  a  limb,  and  they  result  in  gaping 
wounds.  The  immediate  spread  of  each  relaxation  incision  varies 
with  the  tightness  of  the  scar.     In  some  instances  it  is  as  much  as  from 

14 


2IO 


PLASTIC    SURGERY 


6.  to  8.  cm.  (22.5  to  3I5  inches)  at  the  center  of  the  incision.     The  spread 
of  the  first  incision  is,  of  course,  the  widest  (Figs.  155-157). 


Fig.  155. — Unstable  scar  following  a  burn  involving  the  entire  circumference  of  the  leg. 
Duration  twenty-five  months. — i  and  2.  Four  days  after  relaxation  incisions  were  made. 
The  spread  of  the  incisions  were  7.5  cm.  (3  inches),  and  5.625  cm.  (23^1  inches),  and  4.375 
cm.  (i^-:4  inches)  at  their  centers.  These  wounds  were  not  grafted  until  five  days  after 
operation,  as  the  tissue  was  unfavorable  for  immediate  grafting. 


Fig.  156. — Unstable  scar  of  the  leg  continued. — i  and  2.  Two  months  after  grafting. 
Xote  the  individual  grafts  and  the  firm  healthy  condition  of  the  scar  tissue  between  the 
relaxation  incisions.      The  atrophy  of  the  leg  is  beginning  to  disappear. 


Fig.  157. —  Unstable  scar  of  the  leg  continued. — i  and  2.  Taken  six  months  after 
grafting.  The  depressions  have  filled  up  to  the  normal  skin  level.  The  leg  has  developed 
and  the  patient  walks  without  difficulty,  after  being  confined  to  bed  for  twenty-five  months. 

After  the  tension  has  been  reHeved  the  appearance  of  the  scar  tissue 
between  the  incisions  soon  changes  and,  instead  of  the  thin,  glossy 
mottled  look,  the  tissue  seems  to  thicken  and  acquire  greater  stability. 
This  improvement  is  much  more  marked  after  a  few  days. 


SCARS    AND    KELOIDS  211 

When  the  scar  is  stretched  over  a  l)roacl  expanse  of  bone,  such  as  the 
skull,  as  many  horizontal  incisions  as  may  be  necessary  should  be  made 
down  to  the  periosteum.  The  spread  of  relaxation  incisions  over  bone 
is  not  so  marked  as  over  soft  parts  and  some  undercutting  may  have 
to  be  done. 

In  these  cases  the  beneficial  effect  is  more  marked  after  a  week  or  two, 
but  in  the  end  the  result  is  very  satisfactory. 

In  some  cases  of  very  long  standing  the  tissue  exposed  by  relaxa- 
tion incisions  has  atrophied  from  pressure  and  lack  of  use  and  has 
such  a  poor  blood  supply  that  immediate  grafting  is  unwise.  In  these 
cases  it  is  advisable  to  wait  for  several  days  until  the  wounds  are  lined 
with  granulation  tissue,  and  then  apply  the  grafts.  In  other  instances 
immediate  grafting  is  justified,  but  this  point  must  be  determined  at 
the  time  of  the  operation. 

It  is  extraordinary  to  note  the  rapidity  of  healing  of  the  superficial 
ulcers  after  the  relaxation  incisions  have  been  made. 

I  have  used  all  types  of  grafts  on  the  defects  caused  by  the  relaxa- 
tion incisions  with  satisfaction. 

There  has  been  no  recurrence  of  superficial  ulceration  in  any  case 
in  which  the  tension  has  been  completely  relieved  by  the  method 
previously  described. 

By  the  use  of  relaxation  incisions  with  immediate  or  subsequent  skin 
grafting  of  the  defects,  large  unstable  scars  can  be  strongly  healed  in  a 
comparatively  short  time,  and  patients  who  have  been  incapacitated 
for  many  months  can  resume  their  usual  occupation. 

Extensive  Smooth  Scars. — These  scars  may  be  level  with  the  skin 
or  slightly  depressed,  and  may  cause  very  little  trouble.  They  may  be 
smooth  and  movable  over  the  underlying  tissues  and  show  little  tend- 
ency to  contract.  Unless  they  are  situated  on  the  face  or  in  some  other 
conspicuous  position,  it  is  advisable  to  let  them  alone  (Fig.  158). 

Many  methods  have  been  suggested.  Excision  with  skin  grafting 
usually  gives  a  result  more  unsatisfactory  than  the  original  scar,  unless 
a  successful  whole-thickness  graft  can  be  transplanted,  in  which  case  the 
result  is  good. 

The  method  suggested  by  Morestin  of  gradual  partial  excision  is  by 
far  the  best,  and  I  have  found  the  results  most  satisfactory  in  a  number 
of  cases.  In  brief,  the  procedure  is  as  follows:  Excise  an  elliptic- 
shaped  piece  of  the  scar,  having  the  long  axis  in  the  direction  which  is 
judged  most  advisable.  The  size  of  the  ellipse  should  be  limited  only  by 
the  ability  to  approximate  the  edges  after  excision.     The  edges  should 


212 


PLASTIC    SURGERY 


be  sutured  (either  with  or  without  undercutting) ,  and  then  after  a  few 
weeks,  when  the  surrounding  skin  has  stretched,  more  of  the  scar  is 
excised  in  the  same  way,  the  selection  of  the  portions  to  be 
excised  depending  on  conditions.  I  often  allow  several  months  to 
elapse  between  excisions,  especially  if  the  scar  is  on  the  face.     The  final 


Fig.  158. — -Scar  on  cheek  following  a  burn.      Treatment  by  gradual  partial  excision. — 

1.  The  wide  depressed  scar  can  be  seen.      It  is  unsightly  and  in  a  conspicuous  position. 

2.  On  account  of  the  shape,  size  and  situation,  complete  excision  at  one  time  was  impossible. 
An  elliptic  portion  of  the  scar  was  removed  at  the  first  operation,  and  the  edges  were  closed 
without  puckering.  Six  months  later,  after  the  surrounding  skin  had  stretched,  the  re- 
maining portion  was  excised,  and  normal  skin  was  sutured  to  normal  skin,  the  result  being 
a  very  inconspicuous  line  scar. 

result  is  a  linear  scar  which  eventually  can  be  made  quite  inconspicuous. 
This  method  is  unquestionably  the  best  for  the  purpose. 

Contracted  Scars. — The  most  serious  result  of  the  formation  of  scar 
tissue  is  to  be  found  in  what  we  may  term  the  contracted  scar.  There 
is  no  doubt  that  less  scar  tissue  is  formed  in  wounds  of  any  kind  and 
in  any  situation  if  the  healing  is  rapid  and  uncomplicated.     The  main 


SCARS    AND    KELOIDS 


213 


object,    then,   is  for  the  surgeon  to  assist  this  process  in  every  way 
possible. 


Fig.  159. — Contracture  of  the  chin  and  neck  follo^^ing  a  burn. — i.  The  angle  of  the 
mouth  is  drawn  down  and  outward  by  the  scar  which  covers  the  chin  and  neck.  Note  the 
scar  on  the  cheek  and  the  band  connecting  the  chin  with  the  base  of  the  neck  on  the  left 
side.  2.  Result  of  plastic  operation  and  the  shifting  of  flaps  for  the  relief  of  the  neck 
contracture  and  the  drawing  down  of  the  angles  of  the  mouth.  The  fresh  scar  on  the  cheek 
is  the  result  of  gradual  partial  excision  of  the  scar  tissue. 

Contracture  may  take  place  in  any  situation  and  in  spite  of  every 
effort  to  prevent  its  occurrence.  The  regions  in  which  contractures  are 
particularly  liable  to  occur  are  around  joints  and  particularly  where 
extremities  join  the  body. 


Fig.  160. — Contracture  following  a  burn  of  the  face,  neck  and  chest. — Xote  the  eversion 
of  the  lower  lip.  the  tilting  outward  of  the  alveolar  process  and  the  obliteration  of  the  neck. 
The  ear  on  the  left  side  is  pulled  down  by  scar  which  involves  the  cheek  and  chest.  Note 
the  distortion  of  the  areolae  around  the  nipples  by  the  pull  of  the  scar. 


The  majority  of  contractures  on  the  limbs  are  on  the  flexor  side  and 
every  precaution   should  be  taken  during  the  treatment  of  injuries 


214 


PLASTIC    SURGERY 


Fig.  i6i. — Bilateral  ectropion  of  both  lids  due  to  contracture  following  a  burn. — 
Note  the  thickened  mucosa.  The  skin  of  the  entire  face  is  involved  and  there  is  also 
destruction  of  the  alae.  On  account  of  the  scar  tissue  involvement  of  the  surrounding 
tissues  whole-thickness  grafts  should  be  tried  first  to  relieve  the  ectropion,  and  if  not  suc- 
cessful then  split  pedunculated  flaps  from  a  distant  part. 


i  2  3  4 

Fig.  162. — Contracture  of  both  hands  following  a  burn. — i  and  2.      Shows  the  deformity  of 

the  left  hand.     3  and  4.      Shows  the  deformity  of  the  right  hand. 


SCARS    AND    KELOIDS 


21 


Fig.  163. — Distortion  of  the  hand  following  a  third  degree  burn  in  a  child. — Xote  the 
extreme  extension  of  the  little  finger  and  of  the  first  phalanx  of  the  ring  finger.  Relief  may 
be  obtained  in  such  a  case,  after  thoroughly  loosening  the  fingers,  either  by  the  transplanta- 
tion of  whole-thickness  skin,  or  by  the  use  of  a  pedunculated  flap  from  the  abdominal  or 
chest  wall. 


Fig.  164. — Extensive  scarring  of  both  legs  following  a  burn.     Duration  seven  years. 

1.  The  anterior  aspect  of  both  legs  and  thighs  is  covered  with  scar  tissue  which  frequently 
breaks  down.  On  the  inner  side  of  the  left  leg  a  web  of  scar  can  be  seen  extending  from  the 
middle  of  the  thigh  to  the  middle  of  the  leg.      This  prevents  full  extension  of  the  knee. 

2.  Posterior  view.  Xote  the  width  of  the  left  popliteal  space.  The  back  of  the  right  thigh 
and  leg  is  covered  with  a  thick  irregular  mass  of  scar  tissue.  3.  Result  of  removal  of  the 
web  on  the  left  side,  and  the  formation  of  a  popliteal  space  by  shifting  inward  a  long  double 
pedicled  flap  of  slightly  involved  skin  from  the  outer  portion  of  the  posterior  aspect  of  the 
thigh.  The  right  popliteal  space  was  improved  by  excision  and  grafting,  but  the  result  on 
that  side  is  not  satisfactory.  This  is  one  of  the  cases  in  which  extensive  involvement  with 
scar  precluded  the  use  of  pedunculated  flaps  from  the  other  leg  or  thigh. 


2l6 


PLASTIC    SURGERY 


or  burns  of  the  extremities,  or  neck,  to  avoid  this  condition  by  means  of 
over-correction  with  splints,  adhesive  plaster,  plaster  of  Paris,  con- 
tinuous traction  with  weights,  or  continuous  elastic  traction,  etc. 
These  methods,  -uith  proper  massage,  may  also  be  of  use  in  treating  the 
contractures  after  they  are  formed. 

Some  of  the  most  difficult  problems  brought  to  the  plastic  surgeon 
are  those  due  to  contracted  scars.  The  contractures  of  any  duration 
exerting  a  constant  tension  on  bones  (for  instance  of  the  forearm)  will 
A  cause   great  retardation  of  the  growth 

of  the  bone,  and  I  have  seen  in  addi- 

.p    tion  to  the  retardation  marked  bo-^dng 

of  both  bones  of  the  forearm,  and  even 
of  the  femur,  from  the  constant  pull  of 
dense  contracted  scar  tissue  (Figs.  159- 
164J. 

TREATiiEXT. — In  the  relief  of  these 
contractures  the  entire  scar  should  be 
excised,  if  possible,  and  either  the  edges 
closed  or  the  defect  filled  with  a  skin 
graft,  or  with  a  pedunculated  flap. 
B  I    have    seen    very    extensive    con- 

FiG.  165.— Incisions  for  liberating    tractcd  scars  cxtenduig  from  the  shoul- 

a  band  of  scar  tissue  (F.  S.  Mathews).  ,  " 

— The  Hne  AB  represents  the  raised    der  to  the  knee,  which  prevented  an  erect 

band  of  scar  and  along  it  the  incision     „^  ,v:„„         q-i^      „-   „^  eiVp  of  mich   a  ^rar 

is  made  dividing  it  into  two  leaves,    posiuon.     ine  great  size  01  SUCH  a  scar 

FD  and  EC  represent  two  lateral  inci- 
sions. Then  by  traction  the  points  A 
and  B  are  separated,  and  E  is  drawn 
into  the  angle  at  D,  while  F  is  drawn 
to  C.  This  lengthens  the  scar  and 
draws  the  tissues  together  in  an  ir- 
regular line. 


absolutely  prevented  complete  excision, 
and  this  difficulty  was  overcome  and 
the  tension  was  relieved  by  breaking 
the  continuity  of  the  scar  in  several 
places  by  excision  or  division  of  the 
deepest  areas  and  grafting  the  defects,  or  shifting  in  a  pedunculated 
flap. 

Division  of  the  contracting  bands  (with  either  single  or  multiple 
incisions),  has  often  been  tried,  but  in  the  majority  of  instances  there 
will  be  a  recurrence  in  spite  of  the  over-correction  (Fig.  165). 

The  actual  treatment  of  contracted  scars  will  be  subsequently  con- 
sidered more  in  detail  under  the  plastic  surgery  of  the  various  regions. 

Tattooed  Skin  and  Powder  Marks 

The  only  way  to  dispose  of  tattooed  skin  is  to  excise  the  area.  For 
small  areas  the  excLsion  may  be  done  at  one  time  with  immediate  suture; 


SCARS    AND    KELOIDS  21 7 

for  the  large,  partial  gradual  excision  with  suture  each  time  should  be 
employed.  A  large  area  may  be  completely  excised,  and  after  the  edges 
have  been  drawn  in  as  much  as  possible,  the  defect  may  be  grafted. 
Unless  the  full  thickness  of  the  skin  is  removed  the  pigment  cannot  be 
entirely  eliminated.  I  have  proved  this  point  by  transplanting  grafts 
of  whole  thickness  taken  from  a  tattooed  area,  and  have  found  that 
the  pigment  of  several  colors  will  remain  in  the  grafted  area  after  it  has 
healed  in  its  new  position. 

Powder  marks  in  the  skin  are  usually  due  to  an  explosion  of  powder 
close  to  the  part.  If  a  powder  burn  is  seen  when  fresh,  good  results 
may  be  obtained  by  thorough  scrubbing  of  the  area  with  a  stiff  brush 
dipped  in  peroxid  of  hydrogen.  If  the  particles  of  powder  are  well 
scattered,  they  may  sometimes  be  removed  by  inserting  a  blunted  hypo- 
dermic needle  into  each  opening,  and  injecting  peroxid  of  hydrogen 
which  will  bubble  out  the  carbon. 

In  older  cases  there  is  little  to  do  except  to  excise  and  suture,  or  to 
excise  and  fill  the  defect  with  a  graft  or  flap.  In  the  cases  in  which 
particles  of  coal  dust  have  been  driven  into  the  skin  similar  procedures 
should  be  followed.  When  these  substances  have  penetrated  through 
the  skin,  after  the  wounds  have  healed  we  may  have  a  series  of  subacute 
infections  occurring  sometimes  months  apart.  These  should  be  treated 
as  any  other  localized  infection. 

KELOID  (CHELOID) 

Keloid  is  a  dense,  fibrous  growth  in  which  the  blood  vessels  and 
cells  are  far  apart.  This  condition  commences  in  the  corium.  Keloid 
may  develop  in  a  clean  scar,  such  as  that  which  follows  a  per  primani 
healing,  or  spontaneously  in  the  skin.  It  may  also  develop  when  heal- 
ing has  taken  place  over  exuberant  granulations  in  a  sluggish  wound; 
in  other  words  it  is  an  hypertrophied  scar.  The  histological  picture  is 
practically  the  same  wherever  the  growth  develops  (Figs.  166-170). 

It  is  well  known  that  the  negro  race  is  particularly  liable  to  develop 
keloid,  even  in  the  most  trivial  superficial  scar.  Certain  white  indivi- 
duals have  this  same  tendency,  but  why  it  exists  is  not  known.  I  have 
seen  on  the  same  negro  extensive  multiple  keloids  of  the  neck  and  face, 
and  at  the  same  time  smooth,  flat  movable  scars  on  the  arm  with  no 
tendency  to  keloid  in  them.  I  have  also  seen  white  persons  with 
keloid  development  in  every  minor  injury  of  the  skin,  and  in  scars  follow- 
ing clean  operations.     I  have  in  mind  several  instances  in  which  keloid 


2l8 


PLASTIC    SURGERY 


developed  in  a  portion  of  a  clean  appendix  scar,  while  the  rest  of  the 
scar  remained  soft,  fiat,  and  pliable.     It  is  possible  that  some  sub- 


PlG.  i66. — Recurrence  after  excision  of  a  keloid  of  the  wrist  following  an  acid  burn. — 
Note  the  new  growth  extending  from  one  extremity  of  the  incision  to  the  other.  Also  the 
keloid  growth  at  the  site  of  the  sutures.  This  wound  healed  per  primam  and  the  growth 
began  after  several  weeks  had  elapsed. 


Fig.  167. — The  treatment  of  keloid  by  excision  and  whole-thickness  grafting. — i.  An 
extensive  thick  keloid  of  the  wrist  following  a  burn  was  completely  excised  and  the  defect 
covered  with  a  whole-thickness  graft.  2.  Partial  excision  of  a  keloid  almost  surrounding 
the  forearm.  The  area  covered  with  a  whole-thickness  graft  extended  the  length  of  the 
growth  and  from  the  upper  margin  to  a  longitudinal  scar  which  can  be  seen  near  the  lower 
margin  of  the  growth.  The  ultimate  result  is  considerable  improvement  in  most  cases,  but 
in  some  instances  the  graft  also  becomes  involved  with  keloid  tissue.  In  such  cases  the 
grafted  area  will  gradually  become  thinner  and  softer,  and  eventually  be  much  less  objec- 
tionable than  the  keloid  itself.  Sometimes  the  graft  will  be  wholly  successful  and  except 
for  the  marginal  scar  will  replace  the  keloid  with  normal  skin. 

stance  circulating  in  the  blood,  or  which  is  present  in  the  skin,  may  be 
responsible  for  these  growths,  but  this  has  not  yet  been  determined. 


SCARS    AND    KELOIDS 


219 


Fig.  168. — Keloid  following  a  burn  of  the  shoulder,  neck  and  axilla  of  a  white  boy. — 
The  limit  of  abduction  is  shown.  These  keloids  were  partially  excised  and  whole- 
thickness  grafts  were  implanted.  The  result  was  fairly  satisfactory  as  there  was  complete 
restoration  of  function,  and  the  remaining  keloid  softened  considerably.  This  patient 
has  been  under  observation  for  nine  years  since  operation. 


Fig.  169. — Extensive  keloid  on  the  back  and  buttock  of  a  negro,  following  a  burn. — A 
portion  of  the  growth  has  not  yet  become  pigmented,  but  the  pigment  is  extending  in 
from  the  edges,  and  also  in  isolated  patches. 


220 


PLASTIC    SURGERY 


Keloids  are  hard  and  usually  red  and  may  project  above  the  surface 
of  the  skin,  in  some  cases  for  several  centimeters.  They  are  rigid  and 
thus  in  certain  situations  (as  around  joints)  may  interfere  with  function. 
They  often  itch  and  burn.  Some  are  very  large  and  may  be  peduncu- 
lated, and  these  often  break  down  and  ulcerate,  owing  to  poor  circulation. 

Some  keloids,  if  left  alone,  gradually  become  smaller,  but  this  is  the 
exception  rather  than  the  rule. 

The  growth  may  develop  in  any  scar,  great  or  small.  I  have  noticed 
that  it  is  particularly  apt  to  occur  following  acid  burns.  There  is  no 
sure  way  of  preventing  the  occurrence  of  keloid.  The  methods  of 
treatment  are  uncertain,  and  the  liklihood  of  recurrence  is  mostprobable. 


I  2  3  4 

Pig.  170. — Keloid  following  piercing  the  ears  for  ear-rings.  Recurrence.  (Surg. 
No.  26285). — I-  One  year  after  piercing  the  ears.  Note  the  size  of  the  growth.  Thekeloid 
on  the  other  ear  was  about  the  size  of  a  marrow-fat  pea.  The  patient  came  to  the  hospital 
because  there  had  been  rapid  increase  in  the  size  of  the  growth.  Complete  excision  with 
closure  was  possible.  Per  primam  healing.  Recurrence  followed,  and  larger  growths  were 
excised  a  year  later  with  closure,  and  per  primam  healing.  2,  3  and  4.  The  patient  re- 
turned four  years  after  the  second  operation  with  the  condition  shown.  The  growths  on 
the  ear  were  excised,  but  not  closed,  and  several  radium  treatments  were  immediately 
given.  Two  years  later  the  patient  returned  with  an  extensive  recurrence  in  all  areas 
where  there  had  been  operative  interference.  (This  case  was  not  under  my  personal 
care.) 

Methods  of  Treatment. — i.  Excision  and  closure.  (2)  Excision 
and  skin  grafting.  (3)  Partial  gradual  excision.  (4)  X-ray  and  radium. 
(5)  Injection  of  fibrolysin,  etc.     (6)  Freezing  with  carbon  dioxid  snow. 

Excision  and  Closure.  — In  comparatively  small  areas  this  can  be 
done.  If  the  growth  is  an  hypertrophied  scar,  there  is  a  possibility  of 
success  by  this  method,  but  in  the  majority  of  cases  the  growth  recurs 
and  is  larger  than  before.  Furthermore,  keloid  may  also  develop  in 
the  stitch  holes,  and  in  the  needle  wounds  through  which  the  local 
anesthetic  has  been  injected. 

L.  Freeman  suggested  the  underlining  of  incisions  with  strips  of 
fascia  lata  to  prevent  recurrence  of  keloids  in  scars  by  the  elimination 


SCARS    AND    KELOIDS  221 

of  tension,  and  reports  two  cases.  He  says  he  does  not  believe  that 
this  method  will  be  of  much  value,  if  any,  in  spontaneous  keloid. 

Excision  and  Skin  Grafting.- — Excision  with  skin  grafting  has  been 
tried  often,  and  in  extensive  cases  promises  a  fair  amount  of  success. 
I  have  had  considerable  improvement  follow  the  excision  of  large 
keloids  followed  by  Olher-Thiersch  grafting,  and  in  some  of  these  cases 
in  which  complete  excision  was  possible  there  has  been  no  recurrence. 
In  a  few  cases  I  have  used  whole-thickness  grafts  to  fill  in  the  entire 
area  after  excision  and  have  had  fair  success.  When  skin  grafts  are 
used,  the  entire  defect  should  be  covered  with  large  grafts. 

Partial  Gradual  Excision. — IMorestin  has  been  successful  in  the 
treatment  of  keloid  following  an  extensive  burn  by  partial  gradual 
excision,  which  is  done  in  a  manner  quite  similar  to  that  already  de- 
scribed under  scars.  I  have  used  this  method  on  a  few  cases,  and  am 
favorably  impressed  with  it. 

X-ray  and  Radium. — A  number  of  articles  have  appeared  on  the 
value  of  x-ray  and  radium  in  the  treatment  of  keloid,  and  I  sincerely 
hope  that  by  these  rays  this  knotty  problem  may  be  eventually  solved. 
However,  as  a  number  of  these  cases  are  constantly  being  referred  to 
me  by  .T-ray  men,  it  would  seem  that  they  are  not  quite  sure  of  the  suc- 
cess of  this  method.  I  do  feel,  however,  that  x-ray  and  radium  may  be 
very  useful  in  certain  cases,  and  especially  as  a  subsidiary  procedure 
after  excision  and  closure,  or  after  excision  and  skin  grafting.  Curtis 
Burnam  has  suggested  to  me  that  the  radium  or  x-ray  treatment 
should  be  carried  out  first,  and  that  after  the  scar  is  fiat  and  soft  exci- 
sion should  be  done. 

Injection  Method.  Fibrolysin.— At  one  time  the  use  of  fibrolysin 
(thiosinamin  sodium  salicylate),  was  much  exploited  in  the  treat- 
ment of  scar  tissue  and  of  keloid  in  particular.  This  substance  was 
injected  around  the  keloid,  or  at  a  distance  from  it,  every  two  or  three 
days.  The  doses  are  put  up  in  ampules  containing  2.;^  c.c.  of  the  solu- 
tion, equivalent  to  0.2  grams  (3  grains)  of  thiosinamin,  and  the  keloid 
was  supposed  to  soften  and  finally  disappear. 

Tubby  makes  multiple  incisions,  about  0.2  cm.  (slightly  over  }4 
inch)  apart,  across  the  keloid,  and  including  the  subcutaneous  fat  and 
also  about  i.  cm.  (~^  inch)  of  the  normal  skin  on  each  side.  After 
hemorrhage  has  been  checked  he  rubs  in  the  fibrolysin  and  in  addition 
injects  from  10  to  20  minims.  After  the  healing  is  complete  the  process 
is  repeated.     If  necessary,  this  procedure  is  carried  out  several  times. 

IMy  experience  with  this  method  has  been  limited  to  three  or  four 


222  PLASTIC    SURGERY 

cases  and  in  each  case  the  keloid  has  been  larger  at  the  end  of  the  treat- 
ment than  at  the  beginning,  although  possibly  a  good  deal  softer. 

In  my  hands  fibrolysin  has  been  unsatisfactory,  and  I  prefer  some 
of  the  other  methods  of  treatment.  There  seems  to  be  little  danger  if 
it  is  properly  used,  although  I  have  seen  sloughing  of  the  normal  skin 
at  the  site  of  the  injection. 

Various  mixtures  besides  fibrolysin  have  been  used  for  injection 
in  the  treatment  of  keloid.  A  mixture  of  creasote  i  part,  to  pure 
olive  oil  15  parts,  has  been  advocated  by  Lesieur,  who  injects  from 
0.3  c.c.  to  2.  c.c.  beneath  the  skin  near  the  edges  of  the  growth,  but  not 
into  the  keloid.  This  is  repeated  every  two  days  and  good  results  have 
been  reported,  although  long  continued  treatment  may  be  necessary. 

Freezing  with  Carbon  Dioxid  Snow.^ — Carbon  dioxid,  used  either 
as  snow  which  is  molded  into  the  desired  form,  or  compressed  into 
an  opaque  ice  by  means  of  a  special  apparatus,  or  as  a  thick  mush 
mixed  with  ether,  is  often  used  in  the  treatment  of  keloid.  I  have  had 
some  success  with  it  in  the  treatment  of  masses  of  keloid  not  larger 
than  2.5  to  5.  cm.  (i  to  2  inches)  in  diameter.  The  snow  or  ice  should 
be  shaped  to  conform  to  the  mass  of  keloid  to  be  treated  and  the  entire 
surface  covered  by  one  piece  of  snow,  or  different  sections  may  be 
treated  one  after  the  other,  until  the  whole  surface  is  covered.  When 
snow  or  ice  is  used,  the  element  of  pressure  must  be  taken  into  con- 
sideration.    The  treatment  should  last  for  from  one  to  two  minutes. 

When  the  ether  mush  is  used  the  surrounding  skin  should  be  pro- 
tected with  several  layers  of  adhesive  plaster.  Then  a  layer  of  the 
mush  about  0.5  cm.  (}i  inch)  in  thickness  is  applied  with  a  wooden 
spatula  and  is  allowed  to  evaporate.  Occasionally  after  using  carbon 
dioxid  snow  there  is  an  intense  reaction,  although  generally  only  a 
blistering  over  the  treated  area  follows.  This  area  should  be  dried  out 
as  soon  as  possible,  and  after  the  scab  has  come  away  another  treat- 
ment is  given,  the  procedure  being  continued  as  long  as  necessary. 

The  method  is  uncertain,  as  are  all  the  others,  but  occasionally 
good  and  permanent  results  are  obtained. 

BIBLIOGRAPHY 

Scars 
Alexander,  E.  G.     "Anns.  Surg.,"  Oct.,  1914,  451. 

Balleuil,  L.  C.     "Anns.  Surg.,"  July,  1918,  i. 

Blair,  V.  P.     "Surgery  and  Diseases  of  the  Mouth  and  Jaws,"  3d  Ed.,  319. 


SCARS    AND    KELOIDS  223 

Duncan,  C.  H.     "Amer.  Jour.  Surg.,"  May,  1909,  165. 

EssER,  J.  F.  S.     "Surg.,  Gyne.  &  Obst.,"  June,  191 7,  745. 

Hesse,  W.     ".\rch.  f.  klin.  Chir.,"  1916,  cviii,  72. 

M.\THE\vs,  F.  S.     Johnson:  "Operative  Therapeusis,"  iii,  1915,  380. 
MoRESTiN,  H.     "Bull,  et  mem.  Soc.  de  chir.  do  Par.,"  1915,  xli,  1233. 

"Bull,  et  mem.  Soc.  de  chir.  de  Par.,"  1916,  xlii,  2052. 
Me.vrs.     "Med.  Rec."     New  York,  Nov.  19,  1910. 
Mentjel.     "Therapie  d.  Gegenwart,"  1911,  Hi,  155. 
Meriel.     "Rev.  d'orthop."     Paris,  1918,  vi,  203. 

PouL.ARD,  A.     "Presse  med.,"  April  25,  1918,  221. 

Rozies.     "Progress  Med."     Paris,  1914,  xlii,  Xo.  14. 

Sidorenko.     "Deutsch.  Ztschr.  f.  Chir.,"  191 1,  ex,  89. 
Stevenson,  W.  C.     "Lancet."     London,  March  23,  1918,  i,  432. 

Thilo,  O.     "Munchen  med.  Wchnschr.,"  Jan.  2^,  191 2. 

Waugh.     "Amer.  Jour.  Clin.  Med."     Chicago,  1910,  xv,  154. 

Keloids 

Brenizer,  a.  G.     "Anns.  Surg.,"  Jan.,  1915,  83. 

Etiexne,  J.     "Presse  med."     Paris,  March  8,  191 7,  146. 

Freeman,  L.     "Anns.  Surg.,"  Ma\',  1915,  605. 

Gross,  S.     Keloid  Tumors.     ''System  of  Surgery,"  1866,  i,  583. 
Gougerot,  H.     "Paris  ^led.,"  April  14,  191 7,  305. 

Heidingsfeld,  M.  L.     "Jour.  Amer.  ]Med.  Assn.,"  Oct.  16,  1909,  1276. 

Kaposi.     "Pathologic  und  Therapie  der  Hautkrankheiten."     Wien,  1880. 

Lesieur.     "Bull,  et  mem.  Soc.  de  chir.."  Nov.  14,  191 7,  2054. 
Lopes-Sibero,  J.  E.     "Med.  Rec."     New  York,  1917,  xcii,  673. 
Low,  R.  C.     Keloids  and  Angiomata.     Carbonic  Acid  Snow,  191 1. 

Porter.     "Anns.  Surg.,"  July,  1909,  S3-- 

Simpson,  F.  E.     "Jour.  Amer.  Med.  Assn.,"  April  17,  1915,  1300. 
Stelwagon.     "Diseases  of  the  Skin,"  1914. 

Tl-bby,  a.  H.     "Brit.  'Sled.  Jour.,"  Nov.  i,  1913,  1138. 

Vautrin  et  Etienxe.     "Presse  Med.,"  March  8,  191 7. 

Weil,  E.  A.     "Paris  Med.,"  Nov.  27,  1917,  424. 


CHAPTER  X 
MALFORMATIONS 

Quite  a  number  of  congenital  blemishes  and  deformities  are  referred 
to  the  plastic  surgeon,  and  it  seems  advisable  to  consider  them  at  one 
time  in  a  general  group,  rather  than  to  take  them  up  individually  in 
the  sections  dealing  with  the  various  regions  (Figs.  1 71-17  5). 

Angiomata  become  of  interest  to  the  plastic  surgeon  when  their 
situation  is  of  cosmetic  importance,  or  when  their  size  interferes  with 


Fig.  171. — Hemangioma  of  the  scalp.  Congenital. — This  growth  projected  2  cm. 
(^i  inch)  above  the  surrounding  skin.  The  dark  areas  outlined  on  the  skin  are  blood 
stains  following  sUght  nicking  which  occurred  when  the  hair  was  shaved.  This  growth 
was  removed  by  partial  gradual  excision.     No  recurrence  has  followed. 

function.  These  lesions  are  usually  congenital  but  they  may  appear 
within  a  few  weeks  after  birth  and  these  either  result  from  abnormal 
development  of  preexisting  vessels  or  are  due  to  newly  formed  blood  or 
lymph  channels. 

Many  angiomata  are  found  in  situations  corresponding  to  the  em- 
bryonic lines  of  fusion.  Those  made  up  of  blood  vessels  are  called 
hemangiomata,  and  those  made  up  of  lymph  channels  are  called 
l3niiphangiomata. 

224 


MALFORMATIONS 


22: 


Hemangiomata  may  consist  either  of  capillaries,  veins,  arteries,  or 
of  large  vascular  spaces  with  an  endothelial  lining.  All  of  these  varie- 
ties may  be  found  in  one  tumor.  The  tumors  may  \jy.  .'.  Ae  or  mul- 
tiple. They  may  be  found  in  any  tissue  or  organ,  and  on  any  portion 
of  the  surface  of  the  body.     They  are  compressible  and  immediately 


Fig.  172. — Hemangioma  of  the  upper  eyelid. — i.  Note  the  position  and  extent  of  the 
growth.  The  entire  upper  Ud  is  involved  and  the  lid  cannot  be  raised  to  its  full  extent. 
2.  The  result  of  several  gradual  partial  excisions.  The  lid  can  be  raised  normally  and  the 
growth  has  been  eliminated  without  distortion  or  contracture. 

refill  with  blood  when  the  pressure  is  removed.  Some  which  are  com- 
posed principally  of  arteries,  or  in  which  arteries  open  into  the  large 
vascular  channels,  will  pulsate.  It  is  seldom,  if  ever,  that  a  definite 
single  afferent  vessel  is  found,  the  ligation  of  which  will  cause  collapse 
of  the  tumor. 


Fig.  173. — Hemagioma  of  the  tip  of  the  nose. — i  and  2.      Front  and  profile  views, 
case  was  cured  by  partial  gradual  excision. 


This 


Hemangiomata  are  quite  common.  Those  which  are  of  particular 
interest  to  the  plastic  surgeon  are  situated  either  in  the  skin,  the 
mucous  membrane,  or  the  subcutaneous  tissue 

Hemangiomata  always  present  certain  potential  dangers,  the  most 
serious  of  which  is  the  liability  of  hypertrophy  and  possible  develop- 


226 


PLASTIC    SURGERY 


ment  whereby  a  small,  easily  treated  tumor,  may  become  a  large 
growth  which  is  difi&cult  to  treat,  and  which  may  subsequently  cause 
horrible  deformity.  For  this  reason  alone  early  treatment  should  be 
urged,  but  in  addition  we  must  never  forget  the  danger  of  hemorrhage, 
which  may  be  spontaneous  fin  thin-walled  tumors),  or  may  occur  after 
slight  injury.  I  have  seen  several  patients  who  have  been  almost 
exsanguinated  by  such  hemorrhage.     Moreover,  one  must  always  bear 

in  mind  the  possibility  of  a  hemor- 
rhage at  the  time  of  operation,  which 
is  often  severe  and  very  difhcult  to 
check. 

In   the   skin  the  smooth,   bright 
red  ncBvus  flammeus,    or  bluish    red 


Fig.   174.  Pig.   175. 

Fig.  1 74. — Angioma  involving  the  upper  half  of  the  ear.  It  is  continuous  with  an  exten- 
sive angioma  of  the  cheek. — Ten  years  ago  this  growth  was  much  more  extensive.  It 
was  controlled  b^^  tying  off  the  anterior  and  posterior  auricular  vessels,  and  by  multiple 
punctures  with  a  fine  pointed  cautery.  Just  before  this  photograph  was  taken  rapid 
growth  occurred  with  much  pain,  and  several  spontaneous  hemorrhages.  All  blood 
vessels  leading  into  the  growth  were  tied  and  considerable  tissue  was  excised,  only  enough 
being  left  to  suture  over  the  cartilage. 

Fig.  175. — Hemangioma  of  the  lower  lip.  Congenital. — i  and  2.  Profile  and  front 
views.     This  growth  was  removed  by  partial  gradual   excision. 


ncEvus  vinosus,  both  of  which  used  to  be  called  "port-wine  marks," 
are  made  up  of  dilated  capillaries.  Sometimes  the  surface  may  be 
dotted  w4th  red  or  bluish  vascular  nodules.  The  color  of  some  of  these 
growths  is  very  faint  at  birth,  but  develops  rapidly.  In  others  it  is 
brilhant  from  the  first.  Some  of  the  "port- wine  marks"  may  fade  out 
as  the  patient  becomes  older,  but  this  is  the  exception.  These  marks 
often  correspond  to  the  peripheral  distribution  of  a  cutaneous  nerve 
(Gushing  and  others).  The  size  varies  from  that  of  a  pin-head  to  large 
areas;  one-half  of  the  face,  or  the  greater  part  of  a  limb  may  be  impli- 
cated.    Some  of  the  flat  teliangiectases  may  develop  later  into  brilhant 


MALFORMATIONS 


227 


red,  sharply  circumscribed  masses,  which  are  somewhat  lobulated  on 
the  surface  and  which  may  project  several  centimeters  beyond  the  level 
of  the  skin.  The  hemangiomata  in  the  subcutaneous  tissue  usually 
show  through  as  bluish  masses  (Fig.  176) 

Some  hemangiomata  acquire  their  full  growth  within  a  few  weeks 
after  birth,  and  never  tend  to  spread;  others,  after  being  latent  for  a 
long  period,  may  spread  rapidly,  become  cavernous,  and  grow  to  large 
size.  For  this  reason  early  treatment  is  essential,  as  it  is  impossible 
to  determine  whether  a  given  tumor  will  or  will  not    hypertrophy. 

Treatment. — The  treatment  of  hemangiomata  confined  to  the 
skin  varies  with  the  t}-pe. 

Treatment  of  "Port-wine  Marks." — The  smooth  "port-wine  mark"' 
often  situated  on  the  face,  is  verv  difficult  to  handle.     The  result  of 


Fig.  176. — Port- wine  mark  involving  the  face.  Congenital. — Note  that  the  angioma- 
tous involvement  does  not  e.xtend  past  the  midline.  The  warty-looking  areas  are  pro- 
jecting masses  of  angiomatous  tissue  of  a  different  type. 


.r-ray  treatment  is  unsatisfactory.  Curtis  Burnam  tells  me  that  excel- 
lent lasting  results  are  obtained  by  the  use  of  radium  in  the  case  of 
children,  but  that  adults  do  not  respond  nearly  so  well. 

The  Paquelin  or  electric  cautery  has  been  used  with  success,  as  far 
as  destroying  the  brilliant  color,  in  searing  the  '"port- wine  marks," 
but  if  the  burn  is  deep  enough  to  destroy  the  capillaries  a  definite  scar 


2  28  PLASTIC    SURGERY 

is  left.  Multiple  superficial  punctures  with  a  fine-pointed  cautery  have 
been  tried  with  partial  success.  The  electric  needle  has  also  been  used 
with  about  the  same  result.  All  of  these  cauterizing  methods  are 
painful. 

In  my  hands  the  best  results  have  followed  treatment  with  carbon 
dioxid  snow,  either  compressed  or  as  a  mush  in  ether.  Personally,  I 
prefer  the  mush,  for  the  reason  that  much  larger  areas  can  be  treated 
in  a  short  period  of  time.  The  technic  of  application  is  the  same  as  that 
described  under  the  treatment  of  keloids. 

BHsters  will  form,  and  here  and  there  a  superficial  slough  may  occur. 
A  second  treatment  is  given  in  from  lo  days  to  two  weeks  (after  the 
scabs  have  come  away),  this  procedure  being  continued  as  long  as  neces- 
sary. The  color  of  the  area  can  be  made  much  paler  by  this  treatment, 
and  in  many  instances  a  fairly  normal  looking  skin  will  be  left,  although 
scar  tissue  is  always  present. 

During  the  freezing,  and  also  during  the  process  of  thawing,  there  is 
a  good  deal  of  pain  which,  however,  soon  yields  to  continuous  cold  com- 
presses, and  the  associated  swelling  soon  subsides.  In  selected  areas 
where  the  skin  is  lax,  and  the  "port- wine  mark"  is  fairly  small,  excision 
(either  at  once  or  gradually),  with  closure,  is  the  method  of   choice. 

In  areas  which  have  resisted  all  other  methods  of  treatment,  exci- 
sion and  grafting  with  Ollier-Thiersch,  or  whole-thickness  skin  grafts 
may  be  advisable. 

Treatment  of  Arterial  or  Venous  Hemangiomata. — In  small,  simple 
hemangiomata  situated  in  the  skin,  which  project  above  the  skin  level, 
all  of  the  above  methods  may  be  used,  but  the  method  of  choice  is  exci- 
sion and  closure,  as  the  scar  will  be  smaller  than  that  caused  by  the  other 
procedures.  Partial  progressive  excision  may  also  be  used  in  larger 
growths  of  this  type.  In  very  large  areas  excision  followed  by  skin 
grafting  is  advisable. 

The  injection  of  coagulating  substances,  such  as  boiling  water,  into 
these  tumors  has  been  tried  with  more  or  less  success.  Shrinkage  of 
the  growth  is  obtained,  but  in  this  type  of  tumor  such  injections  are 
often  followed  by  serious  sloughing. 

The  x-ray  and  radium  have  proved  disappointing  in  the  treatment 
of  these  tumors  and,  as  far  as  I  have  seen  is  not  dependable. 

Treatment  of  Cavernous  H!emangiomata. — Cavernous  hemangio- 
mata have  proved  very  difficult  to  handle.  G.  B.  New  has  obtained 
splendid  results  in  some  of  these  cases  in  children  by  burying  radium 
(radium  emanations  may  also  be  used  in  the  same  way),  in  the  substance 


MALFORMATIONS 


229 


of  the  tumor  and  allowing  it  to  remain  there  for  the  required  time. 
This  is  a  great  improvement  over  the  external  application  of  radium, 
and  New  reports  comparatively  little  external  scar  following  this 
method.  In  a  personal  communication,  he  says  that  the  results  in 
older  patients  are  not  so  satisfactory  and  that  a  white  scar  may  result. 

The  treatment  of  cavernous  hemangiomata  with  the  a;-ray  seems  to 
have  been  a  failure,  from  the  cosmetic  standpoint  at  least.  I  have 
had  several  patients  under  my  care  who  had  been  submitted  to  multiple 
exposures  to  :ij-ray  and  whose  hemangiomata  had  undoubtedly  been 
cured,  but  unfortunately  at  the  same  time  the  entire  part  involved 
sloughed  away  and  had  to  be  reconstructed  from  other  tissues. 

The  infection  of  boiling  water  into  this  group  of  tumors  was  first 
tried  by  John  A.  Wyeth  of  New  York,  and  the  method  was  elaborated 
later  by  F,  Reder  of  St.  Louis.  It  is  certainly  effective  so  far  as  de- 
stroying the  growth  is  concerned. 

In  brief,  the  method  is  as  follows:  General  anesthesia  is  necessary. 
The  surrounding  skin  should  be  protected  with  moist  cloths  to  prevent 
scalding.  To  guard  against  possible  embolism  it  is  necessary  to  make 
peripheral  compression  while  the  injection  is  being  made.  This  can 
easily  be  accomplished  by  using  flexible  lead  tubing,  which  can  be 
shaped  to  surround  the  growth,  and  should  be  pressed  firmly  into  the 
skin  during  the  process  of  injection. 

The  hands  of  the  operator  should  be  protected  by  several  pairs  of 
rubber  gloves,  or  gloves  of  thick  washable  leather.  The  water  (which 
should  be  as  nearly  at  the  boiling  point  as  possible) ,  is  injected  from  a 
glass  syringe  through  a  slip  needle,  which  is  inserted  into  the  normal 
skin  about  0.5  or  i.  cm.  {}i  or  %  inch)  from  the  tumor.  In  small 
tumors  the  whole  area  may  be  injected  at  one  time;  in  tumors  of 
large  size  the  injections  may  be  made  in  only  a  portion  of  the  tumor,  the 
other  portions  being  treated  later. 

Hyperdistention  almost  inevitably  produces  sloughing,  and  every 
effort  should  be  made  to  avoid  it  on  account  of  the  delayed  convales- 
cence and  the  subsequent  scar.  When  the  skin  begins  to  turn  a  greyish 
color  the  injection  into  that  portion  should  be  discontinued. 

The  water  should  be  injected  slowly.  In  large  tumors  several 
ounces  may  be  put  in  at  a  sitting.  Care  should  be  taken  that  every 
portion  of  the  tumor  is  injected.  A  good  deal  of  swelling  usually  occurs 
immediately  after  the  injection,  but  may  be  controlled  by  the  use  of 
cold  compresses.  The  treatments  should  be  two  or  three  weeks  apart, 
and  quite  a  number  of  injections  may  be  necessary  to  accomplish  a  cure. 


230  PLASTIC    SURGERY 

The  final  result,  unless  sloughing  has  occurred,  will  show  a  fairly  normal- 
looking  skin,  although  the  formation  of  a  visible  scar  is  unavoidable  if 
the  tumor  has  been  in  the  skin  itself. 

Morestin  uses  a  mixture  of  equal  parts  of  90  per  cent,  alcohol, 
glycerin  and  formalin,  for  injection,  and  reports  good  results.  He  uses 
from  7.  to  12.C.C.  at  a  sitting,  being  very  careful  not  to  inject  more  than  a 
few  drops  in  one  place  for  fear  of  a  slough, 

I  have  used  both  of  these  injection  methods,  and  have  had  success 
in  a  certain  number  of  cases.  The  coagulating  fluids  have  the  advan- 
tage of  forming  scar  tissue,  and  I  have  employed  them  for  this  purpose 
in  very  extensive  growths  whose  character  contraindicated  successful 
operative  interference  on  account  of  probable  fatal  hemorrhage.  In 
these  cases,  after  sufficient  scar  tissue  is  formed,  operative  interference 
may  be  undertaken  without  danger. 

I  have  noted  symptoms  of  embolism  in  face  cases  after  injections 
of  boiling  water,  and  also  of  the  alcohol,  formalin  and  glycerin  mixture, 
but  fortunately  these  symptoms  soon  subsided. 

It  is  almost  impossible  to  cure  one  of  these  growths  and  leave 
normal  looking  skin  if  the  skin  itself  is  involved.  For  this  reason 
excision  is  preferable  if  it  can  be  done  with  safety.  The  growth  may 
be  removed  at  one  time,  or  in  stages.  It  may  be  necessary  to  tie 
arteries  and  veins  (such  as  the  facial,  temporal,  or  external  carotid), 
in  dealing  with  growths  on  the  face,  and  even  then  the  hemorrhage 
may  be  alarming  and  difficult  to  check.  Excision  may  be  used  in  con- 
junction with  the  injection  method  in  very  bad  cases. 

In  cavernous  hemangiomata  of  the  nose  or  cheek,  the  underlying 
bones  are  often  hypertrophied.  In  the  operative  treatment  it  may  be 
necessary  to  chisel  off  these  thickened  portions. 

In  large  cavernous  hemangiomata  of  the  cheek  or  nose,  on  several 
occasions  I  have  transfixed  the  growth  in  various  directions  with  blunt 
steel  pins,  used  on  the  same  principle  as  Wyeth's  hip-joint  pins,  and 
by  means  of  elastic  compression  have  obtained  a  comparatively  blood- 
less field. 

Lymphangiomata. — The  tumors  are  very  similar  to  hemangiomata, 
except  that  they  are  composed  of  lymph  vessels;  they  may  also  take 
on  an  abnormal  growth  at  any  time.  The  cavernous  type  is  of  interest 
to  the  plastic  surgeon,  as  macroglossia  and  macrochelia  are  due  to 
the  presence  of  lymphangioma  and  are  often  difficult  to  treat.  New 
has  had  good  results  from  radium  in  lymphangioma  of  the  tongue 
and  considers  this  the  best  treatment.     He  uses  either  external  ap- 


MALFORMATIONS 


231 


plications,  or  else  incises  and  buries  the  radium  as  in  cavernous  hem- 
angioma. The  .v-ray  seems  useless  in  the  treatment  of  this  type  of 
tumor  (Fig.  177). 

I  have  had  under  my  care  an  extensive  cavernous  lymphangioma 
of  long  duration  covered  with  dense  leathery  skin,  which  could  only  be 
successfully  treated  by  operative  methods.  Gradual  partial  excision 
with  final  plastic  readjustment  was  employed. 

In  the  dense  thickening  of  the  skin  with  heavy  folds  which  we  some- 
times lind.  operative  measures  are  our  only  resource. 

Hypertrophy  of  the  Tongue  (Macroglossia). — Hypertrophy  of 
the  tongue  is  caused  by  a  cavernous  lymphangioma  involving  the 
submucous  connective  tissue  and  sometimes  the  muscle  of  the  tongue. 


Fig.  177. — Lymphangioma  (congenital)  of  the  thumb. — The  growth  surrounded  the 
thumb  from  the  base  of  the  nail  to  the  metacarpophalangeal  joint.  It  was  removed  by 
partial  gradual  excision. 

It  may  implicate  the  whole  tongue  or  only  a  portion  of  it.  The  tongue 
may  be  enlarged  at  birth,  or  rapid  subsequent  increase  in  size  of  a  pre- 
viously small  growth  may  develop.  The  enlargement  is  sometimes 
so  great  that  breathing,  eating  and  talking  are  interfered  with,  and  the 
rehef  of  this  condition  calls  for  radical  surgical  measures. 

Treatment. — If  the  hypertrophy  is  localized,  this  part  may  be  ex- 
cised and  the  edges  sutured.  When  the  entire  tongue  is  involved,  a 
deep  wedge  of  tissue  may  be  removed  from  the  tip  or  from  some  other 
part  selected,  and  the  wound  closed.  It  may  be  necessary  temporarily 
to  block  or  to  tie  the  lingual  arteries  in  extensive  cases,  and  sometimes 
tracheotomy  is  indicated. 

When  the  tongue  is  simply  enlarged  so  that  its  edges  are  being 
constantly  bitten,  Butlin's  operation  of  marginal  resection  as  modified 
by  Handley,  is  useful.     The  tongue  is  transfixed  far  back  with  a  strong 


232 


PLASTIC    SURGERY 


Fig.  178. — Method  of  excising  a  wedge  of  tissue  from  the  tip  of  the  tongue  for  hyper- 
trophy.— Note  the  position  of  the  posterior  suture  which  should  be  tied  as  soon  as  the 
wedge  is  removed,  to  check  hemorrhage. 


t  -     -J\ 


(-^     ^-^V 


Fig.  179. 


(..) 


C-  -.> 


34  5 

Fig.  180. 
Figs.  179  and  180. — Modification  of  Butlin's  operation  for  marginal  resection  of  the 
tongue  {Hundley ). — i.  Shows  the  primary  incision  with  sutures  placed,  which  close  the 
wound  and  prevent  bleeding.  2.  The  tongue  is  controlled  by  traction  on  sutures  and 
tenaculum  forceps.  Note  the  angle  of  the  knife  in  making  the  incisions.  3.  Shows  the 
shape  of  the  defect  after  removal  of  the  wedge-shaped  area  of  marginal  tissue.  4.  The 
excision  has  been  completed  on  one  side  and  the  sutures  placed.  5.  The  result  after  com- 
pletion of  operation. 


MALFORMATIONS 


233 


silk  thread  by  which  it  can  be  controlled.  The  tip  is  grasped  with  a 
tenaculum  forceps  and  pulled  forward.  A  transverse  incision  about 
2.5  cm.  (i  inch)  long  is  made  on  the  dorsum  of  the  tongue  parallel 
with  the  tip.  The  tongue  is  lifted  and  a  corresponding  incision  is  made 
below  at  the  junction  of  the  rough  mucosa  of  the  surface  with  the  smooth 
mucosa  of  the  inframarginal  portion.  These  incisions  are  made  so  as 
to  cut  out  a  wedge-shaped  segment,  but  the  segment  is  left  attached 
at  each  end  to  the  tongue.  The  edges  of  the  wedge-shaped  defect 
are  sutured  immediately  and  bleeding  is  thus  controlled.  The  excision 
of  the  wedge  is  gradually  continued,  sutures  being  inserted  as  the 
tissue  is  removed.  The  wedge  is  made  more  and  more  shallow  until 
the  level  of  the  last  molar  tooth  is  reached,  when  the  tissue  is  cut  away 
entirely  from  the  tongue  on  that  side.     A  similar  procedure  is  then 


Fig.  181. — Macrocheilia.  (Surg.  No.  29870). — The  mild  grade  of  lymphangioma  of  the 
upper  lip  shown  in  this  case  was  cured  by  the  excision  of  wedges  of  tissue.  The  tongue  was 
also  somewhat  thickened  but  not  enough  to  require  operative  interference. 


carried  out  on  the  other  side.  This  is  an  excellent  operation.  No 
blood  is  lost,  the  operator  has  absolute  control  of  the  situation  at  all 
times,  and  the  necessity  for  tracheotomy  is  eliminated.  This  method 
may  also  be  used  when  only  one  side  of  the  tongue  is  involved  (Figs. 
178-180). 

Hypertrophy  of  the  Lips  (Macrochelia). — Occasionally  we  find 
hypertrophy  of  one  or  both  lips  due  to  a  lymphangioma.  This  may 
vary  in  size,  in  some  instances  being  so  extensive  that  the  weight  and 
thickness  cause  complete  eversion  of  the  lower  lip.  In  the  more 
marked  cases  the  motion  of  the  lip  is  interfered  with.  The  char- 
acteristics of  these  growths  are  those  of  ordinary  lymphangioma  which 
have  been  discussed  elsewhere  (Fig.  i8i). 

Treatment. — Radium  is  said  to  give  good  results.  In  extensive 
cases  injections  of  boiling  water  or  other  coagulating  fluids  may  be 
useful,  and  if  the  growth  is  not  destroyed  by  these  measures  we  have 


234  PLASTIC    SURGERY 

at  least  the  formation  of  scar  tissue,  which  may  faciHtate  operative 
procedures. 

Excision  is  the  method  of  choice.  This  may  be  done  at  one  time 
when  the  involvement  is  not  too  extensive,  or  in  stages.  The  excised 
areas  should  be  so  planned  as  to  avoid  puckering  and  distortion  of  the  lip. 

Moles  (Extensive). — Extensive  moles  are  usually  congenital,  or 
appear  shortly  after  birth.  They  vary  in  size,  but  may  be  very  large, 
sometimes  covering  a  considerable  portion  of  the  face,  or  of  a  limb. 
The  color  varies  from  a  faint  brown  to  a  jet  black  (Fig.  182). 


Fig.  182. — Extensive  hairy  mole  of  the  cheek.  Congenital. — i.  Note  the  size  of  the 
mole.  It  extends  from  the  angle  of  the  mouth  nearly  to  the  lobule  of  the  ear.  2.  One 
month  after  excision.  The  skin  of  the  cheek  below  was  shifted  up  to  partially  cover  the 
defect  after  a  relaxation  incision  was  raade,  and  the  raw  surfaces  were  grafted. 

Some  of  these  moles,  at  birth,  are  depressed  slightly  below  the  level 
of  the  surrounding  skin,  and  may  be  soft  and  velvety  to  the  touch  and 
without  hair.  Others  may  project  definitely  beyond  the  skin  level, 
and  be  thick,  pebbly  and  covered  with  hair.  The  growth  of  hair  may 
be  thick  or  scanty,  short  or  long,  fine  or  coarse. 

Treatment. — The  best  and  safest  treatment,  on  account  of  the  lia- 
bility of  subsequent  malignant  degeneration,  is  early  excision  at  one 
operation,  if  possible;  or  if  the  growth  is  very  large,  in  stages.  I  have 
often  excised  these  growths  and  filled  in  the  defect  with  a  pedunculated 
flap,  or  with  an  Ollier-Thiersch,  or  whole-thickness  graft,  and  have  had 
good  results.  Carbon  dioxid  snow  may  be  used  with  success  on  small 
areas  without  much  hair. 

Supernumerary  Digits  (Polydactylism) 

By  polydactylism  is  meant  the  presence  of  an  excess  number  of 
fingers  or  toes.     In  many  instances  heredity  can  be  traced. 


MALFORMATIONS 


235 


Fig.  183  . — Supernumerary 
thumb. — Amputation  with  proper 
trimming  of  the  projecting  articu- 
lation was  done. 


Fig.    184. — Polydactylism.      (X-ray  Xo. 
35961). — Double  little  toe. 


Fig.  185. — Polydactylism.      (A'-ray  No.  22252). — Five  fingers  and  a  thumb,  all  of   which 

functionate  normally.  ^ 


236  PLASTIC    SURGERY 

The  deformity  may  be  unilateral  or  bilateral,  or  the  hand  and  foot 
on  the  same  side  may  be  involved.  As  many  as  13  fingers  on  each  hand 
and  12  toes  on  each  foot  have  been  reported.  The  fifth  finger  is  most 
often  double. 


Fig.  186. — Thickened  thumb  with  double  fused  terminal  phalanx  (X-ray  No.  46359). 

The  covering  of  the  extra  digits  may  be  composed  only  of  skin  and 
subcutaneous  tissue,  or  all  the  normal  soft  parts  may  be  present.  The 
extra  finger  may  approach  normal  development  and  voluntary  function 


Fig.  187. — Cloven  hand  (X-ray  No.  3377). — The  thumb  and  little  finger  are  present 
although  deficient  in  phalanges.  Note  the  stumps  of  the  metacarpal  bones  between 
Much  can  be  done  to  improve  the  usefulness  of  a  hand  of  this  type  by  plastic  operations 

may  be  possible.  It  may  articulate  with  the  fifth  metacarpal  bone, 
or  the  extra  finger  may  be  attached  only  by  a  pedicle  of  skin.  On 
the  thumb  there  may  be  all  the  varieties  mentioned  above,  and,  in 


MALFORMATIONS 


237 


Fig.   x88.  Fig.   189. 

Fig.  188. — Hypertrophy  of  the  toes,  associated  with  a  fibrolipoma  of  the  sole  of  the  foot. 
The  best  treatment  in  a  case  of  this  kind  is  the  removal  of  the  lipoma  and  amputation  or 
shortening  of  the  toes,  depending  on  conditions. 

Fig.  189. — Congenital  deformity  of  the  toes. — The  second  and  third  toes  are  missing, 
the  space  being  occupied  by  a  large  fibrolipoma  which  extends  half  way  down  the  sole  of 
the  foot,  and  also  between  the  metatarsal  bones  to  the  dorsum.  Excision  is  the  method  of 
choice  in  cases  of  this  type. 


Fig.  190. — Gigantism  of  the  toe. — Note  the  size  of  the  hypertrophied  toe  in  comparison 
with  the  great  toe.  Amputation  is  the  method  of  choice  in  this  case,  as  the  phalangeal 
bones  are  also  much  hypertrophied. 


238 


PLASTIC    SURGERY 


addition,  the  metacarpal  bone  may  be  divided  and  much  distorted 
(Figs.  183-187). 

Treatment. — The  removal  of  the  supernumerary  digits  which  are 
attached  only  by  skin,  should  be  by  an  elliptic  incision.  The  cor- 
rection of  the  more  marked  deformities  should  be  most  carefully  done, 
and  with  the  aid  of  the  a'-ray  a  useful  finger  in  the  proper  line  may  be 
produced,  although  several  operations  may  be  necessary  to  accomplish 
this.  The  work  is  ordinarily  done  by  the  orthopedist,  but  occasionally 
the  plastic  surgeon  is  called  upon  in  special  cases. 

Supernumerary  toes  are  less  common  than  fingers.  The  extra 
toe  is  usuallv  found  connected  with  the  first  or  fifth  toe,  and  as  a  rule 


Fig.  191. — Congenital  malformation  of  the  foot. — i  and  2.  Compare  the  two  feet. 
There  is  marked  enlargement  of  the  anterior  half  of  the  foot  with  enormous  increase  in  size 
of  the  great  toe,  and  the  two  adjacent  toes,  which  are  fused.  The  bones  of  these  toes 
are  also  enlarged.  Note  the  two  normal  sized  toes.  The  hypertrophy  is  due  to  a  fibro- 
lipoma.  The  treatment  was  amputation  of  the  hypertrophied  toes  and  partial  gradual 
excision  of  the  other  portions  of  the  tumor. 

the  phalanges  only  are  duplicated.  The  surgical  treatment  is  prin- 
cipally for  the  purpose  of  making  it  possible  to  wear  an  ordinary  shoe. 

Macrodactylia. — Quite  frequently  cases  of  gigantic  development  of 
one  or  more  fingers  or  toes,  or  portions  of  the  hands  or  feet,  are  found. 
They  are  usually  congenital  and  may  be  due  to  obstruction  of  lymph 
channels,  or  to  the  presence  of  fibrolipomata. 

Treatment. — In  some  instances  it  is  possible  by  multiple  excisions 
and  plastic  procedures  to  reduce  the  size  of  the  hypertrophied  part. 
On  several  occasions  T  have  removed  large  masses  of  tissue  in  order  to 
reduce  the  size  of  the  foot  so  that  a  shoe  could  be  worn.  Frequently 
amputation  of  the  fingers  or  toes  is  indicated.     There  is  no  definite  rule 


MALFORMATIONS  239 

to  follow  in  these  cases,  except  to  give  the  patient  an  extremity  which 
will  be  as  useful  as  possible,  and  which  at  the  same  time  will  not  be  too 
conspicuous  (Figs.  188-19 1). 

Syndactylism  (Webbed  Fingers  or  Toes) 

This  type  of  deformity  varies  greatly  in  degree.  The  normal  web 
may  be  simply  increased  downward  for  a  greater  distance  than  normal, 
or  it  may  extend  to  the  ends  of  the  fingers.  The  web  may  consist  of 
skin  only,  and  may  be  loose  enough  to  allow  the  fingers  to  be  separated 
to  a  considerable  extent.     In  many  cases,  however,  it  is  thick,  consisting 


Fig.  192. — Unilateral  syndactylism. — The  nails  are  not  fused  and  there  is  no  bony 
union.  The  groove  between  the  fingers  is  fairly  well  marked  down  to  the  first  inter- 
phalangeal  joint.      There  is  no  family  history  in  this  case.      Operation  refused. 

of  skin  and  underlying  soft  parts,  and  extends  to  the  ends  of  the  fingers, 
there  being  only  a  groove  on  each  side  to  indicate  the  line  of  separation. 
In  some  the  fingers  are  closely  fused,  the  nails  being  joined,  and  in 
extreme  cases  the  phalangeal  bones  also.  The  terminal  phalangeal 
bones  are  those  most  frequently  fused. 

Syndactylism  is  likely  to  be  hereditary.  A  case  has  recently  come 
under  my  care  with  the  following  history:  The  patient's  maternal  great 
grandmother  had  fusion  of  the  ring  and  middle  fingers  of  both  hands. 
The  maternal  grandfather,  who  was  the  seventh  of  eight  children,  had 
the  same  fingers  of  one  hand  involved.     The  mother,  who  is  the  third 


240 


PLASTIC    SURGERY 


of  five  children,  had  fusion  of  the  same  fingers  on  one  hand.  The 
patient,  who  is  the  first  of  two  children,  has  the  middle  and  ring  fingers 
of  both  hands  completely  fused.  All  the  other  members  of  these 
families  had  normal  hands  (Figs.  192  and  193). 

Two  fingers  may  be  fused  on  only  one  hand,  or  all  the  fingers  on 
both  hands  may  be  involved.  It  is  a  great  mistake  to  operate  for 
this  condition  on  a  young  child.  It  is  much  better  to  wait  until  the 
sixth  or  seventh  year,  but  the  operation  should  not  be  delayed  much 
later  than  this,  especially  in  severe  cases,  inasmuch  as  retarded  develop- 
ment may  occur  if  the  fingers  are  not  separated. 

It  is  inadvisable  to  operate  on  the  toes  for  this  deformity. 

The  successful  treatment  of  syndactylism,  however  small  the  degree 
of  the  deformity,  is  difificult.     The  key  to  the  operative  success  is  the 


Fig.  193. — Congenital  absence  of  the  ring  and  little  fingers.  Syndactylia  of  the  index 
and  middle  fingers. — The  fused  fingers  may  be  separated  by  one  of  the  operations  described 
in  the  text. 


formation  of  a  new  commissure  which  is  somewhat  higher  than  normal, 
and  healing  with  the  minimum  amount  of  scar  tissue. 

In  separating  closely  fused  fingers,  gangrene  of  one  or  both  fingers 
has  occurred  on  account  of  interference  with  the  blood  supply,  which 
may  not  be  normal  in  arrangement.  This  possibility  should  be  men- 
tioned when  giving  a  prognosis  to  the  family. 

Operative  Treatment. — In  the  loose  thin  web  the  skin  may  be 
divided  and  the  edges  approximated  without  tension,  but  even  in  these 
cases  it  is  difficult  to  prevent  partial  recurrence,  unless  the  formation 
of  the  commissure  is  assured.  The  old  method  was  to  produce  a  fistula 
by  perforating  the  base  of  the  web  and  inserting  a  glass  or  rubber  tube, 
or  a  piece  of  heavy  silver  wire,  which  was  held  in  place  until  the  healing 
was  complete  all  around  the  opening,  after  which  the  web  was  divided 


MALFORMATIONS 


241 


and  the  edges  were  closed.     This  is  an  unsatisfactory  method  and  has 
been  for  the  most  part  abandoned. 

Tubby,  however,  still  believes  that  a  permanent  fistula  should  be 
formed  first,  and  that  later  the  rest  of  the  fused  portions  should  be 
separated  by  the  appropriate  operation.     In  order  to  make  this  epithe- 


PiG.  194. — Didot's  operation  for  syndactylism  (Burghard). —  i.  The  fused  fingers 
X  and  Y.  The  anterior  and  posterior  flaps  marked  by  the  lines  AB  and  CD,  are  raised. 
2.  Transverse  section  showing  method  of  raising  the  flaps  separating  the  fingers  and  closing 
the  defect. 

Hum  lined  fistula,  he  raises  two  triangular  flaps  of  skin  and  subcutaneous 
tissue  at  the  situation  of  the  interdigital  cleft.  The  palmar  flap  is  cut 
in  the  reverse  direction.  The  dorsal  flap  is  cut  higher  on  the  hand 
because  of  the  slope  of  the  natural  web  from  below  backward  and  up- 
ward.    These   flaps   should  be  as  large  as  possible.     The  soft  tissues 


Fig.   195. — Didot's  operation,  continued  (Burghard). — ^The   flaps  raised  and   the   fingers 
separated  exactly  in  the  midline. 

which  remain  after  raising  the  flaps  are  excised  completely.  Then  the 
flaps  are  drawn  through  this  opening  and  sutured,  so  as  to  line  it  as 
completely  as  possible.  A  glass  rod  of  the  size  desired  is  then  inserted, 
and  is  held  in  position  by  a  special  apparatus,  the  dressings  being  applied 
with  anterior  and  posterior  splints.     In  due  time  the  fistula  will  be 


242 


PLASTIC    SURGERY 


found  lined  with  epithelium,  after  which  the  rest  of  the  web  may  be 
separated  by  Didot's  or  Nelaton's  method  (Figs.  194-196). 


cC 


Fig.  196. — Method  of  covering  the  index  and  little  finger  with  skin  in  syndactylism 
involving  all  the  fingers  (J.  S.  Stone). — The  ring  and  little  fingers  may  be  completely 
covered  by  the  flaps  CDB  and  A'DB'.  The  denuded  surface  left  after  removal  of  the  flaps 
may  be  grafted,  or  may  be  covered  with  a  pedunculated  flap  from  the  abdomen. 

Didot's  or  Nelaton's  Operation.^ — In  this  operation  a  flap  is  raised 
from  the  midline  of  the  dorsum  of  one  finger,  and  from  the  midline 
of  the  palmar  surface  of  the  other.  The  flaps  should  extend  from 
the  extremity  of  the  web  back  to  the  location  of  the  normal  web. 


Fig.  197. — Operation  for  syndactylism  (Agnew). — i.  The  dotted  line  indicates  the 
flap,  which  is  much  more  blunt  than  in  the  original  operation.  2.  The  web  divided  and  the 
flap  sutured  into  the  palm.  The  lateral  skin  edges  are  also  sutured.  This  is  only  possible 
when  the  web  is  comparatively  lax  and  thin. 

After  the  flap  has  been  raised  the  tissues  uniting  the  fingers  should  be 
divided  exactly  in  the  midline  to  avoid  interference  with  the  circulation. 
When  the  bones  are  fused  they  should  be  separated  with  a  thin-bladed 


MALFORMATIONS 


H3 


chisel,  and  the  sharp  edges  rounded  off.  Then  the  skin  flaps  should  be 
brought  around  to  cover  the  raw  surface  of  the  finger  to  which  it  is 
attached,  and  should  be  sutured  with  interrupted  horsehair  sutures. 


Fig.  198. — Operation  for  syndactylism  (Bidwell). — The  dotted  lines  [indicate  the 
position  of  the  incisions.  The  ape.x  of  the  triangular  flap  shown  on  the  dorsal  surface  is 
sutured  to  the  palm.  The  skin  flap  from  the  dorsum  of  the  middle  finger  is  sutured  to  the 
skin  of  the  palm  of  the  index  finger,  and  will  cover  it.  This  leaves  normal  skin  on  the 
palmar  surface  of  the  middle  finger.  Uncovered  areas  may  be  skin  grafted,  or  may  be 
closed  by  pedunculated  flaps.  This  operation  is  an  excellent  one  and  with  some  modi- 
fications I  have  used  it  with  satisfactorv  results. 


Fig.  199. — Method  of  forming  the  commissure  in  syndactylism  (Felizet). — i.  The 
flaps  are  secured  from  the  palmar  and  dorsal  surfaces  of  the  web  and  are  overlapped  and 
sutured  edge  to  edge.  By  this  method  a  broad  thick  commissure  may  be  formed.  The 
shape  of  the  flaps  must  necessarily  vary  according  to  the  type  of  web.  I  have  used  this 
method  in  conjunction  with  a  modified  Didot  operation,  and  grafted  the  uncovered 
areas,  and  find  it  most  useful. 


Diagrammatically  this  is  an  ideal  operation.  As  a  matter  of  fact,  how- 
ever, it  is  difficult  to  carry  out,  since  the  flaps  are  seldom  large  enough  to 
cover  the  raw  surface   completely.     If  they  are  sutured  with  much 


244 


PLASTIC    SURGERY 


tension  sloughing  is  liable  to  occur.     In  fact  the  commissure  seldom 
proves  satisfactory  if  these  directions  are  carried  out. 

Where  the  web  is  wide  the  commissure  may  be  made  by  the  method 
devised  by  Agnew.  He  raises  a  single  large  triangular  flap  from  the 
dorsum,  its  base  being  at  the  metacarpophalangeal  joint,  and  the  apex, 


Fig.  200. — Bilateral  syndactylism  of  the  middle  and  ring  fingers. — i  and  2.  The  nails 
of  both  hands  are  fused  and  there  is  union  of  the  terminal  phalanges  in  the  right  hand,  with 
tilting  outward  of  the  fused  phalanges.  The  tilting  outward  of  the  terminal  phalanges  of 
the  other  hand  is  less  marked.  Only  one  hand  should  be  operated  on  at  a  time  in  these 
cases.  3.  Two  weeks  after  operation  on  the  right  hand.  Note  the  tilting  of  the  separated 
terminal  phalanges. 

which  should  be  rounded,  reaching  nearly  to  the  second  phalangeal 
bone.  He  then  divides  the  web  completely,  brings  forward  the  flap, 
sutures  it  into  the  palm,  and  then  closes  the  edges  along  the  fingers 
(Figs.  197  and  198). 

In  the  formation  of  a  commissure  I  prefer  to  use  two  pedunculated 
flaps,  one  of  which  is  raised  on  the  dorsum  of  the  fused  fingers  with  its 


Fig.  201. — Bilateral  syndactylism,  continued. — i.  Two  weeks  after  operation  on  the  left 
hand,  and  one  year  after  operation  on  the  right  hand.  2.  Two  years  after  operation  on  the 
right  hand,  and  eight  months  after  operation  on  the  left  band.  If  the  tilting  of  the  fingers 
cannot  be  overcome  by  massage  and  splinting  at  night,  then  operative  procedure  is  indi- 
cated. Both  of  these  operations  were  done  by  the  formation  of  a  commissure  with  flaps, 
and  then  by  a  modified  Didot  operation  on  the  fingers,  with  grafting  when  necessary. 

base  at  the  metacarpophalangeal  joint,  and  the  other  on  the  palm. 
The  main  portion  of  the  bodies  of  these  flaps  are  on  different  fingers, 
the  extremities  are  blunt,  and  when  sutured  they  he  side  by  side  rather 
than  end  to  end,  somewhat  after  the  method  of  Felizet  (Fig.  199). 


MALFORMATIONS  245 

In  any  operation  for  webbed  fingers  primary  healing  is  so  important, 
that,  if  the  skin  edges  cannot  be  sutured  without  tension,  we  must  resort 
to  one  of  the  methods  of  skin  grafting  to  fill  the  defect.  I  have  used 
Ollier-Thiersch  grafts  and  whole-thickness  grafts  with  success  in  these 
cases,  and  do  not  hesitate  to  sacrifice  the  skin  at  the  proximal  portion 
of  the  web  on  both  the  dorsal  and  palmar  surface  of  the  fingers,  in 
order  to  construct  a  flexible,  broad  commissure.  Then,  by  a  modified 
Didot  operation  the  remainder  of  the  web  is  removed,  and  if  any  defects 
remain,  they  are  grafted  (Figs.  200  and  201). 

Pedunculated  flaps  from  distant  parts  may  also  be  used  to  fill  in 
any  remaining  defects,  and  in  certain  difhcult  cases  even  to  form  a 
commissure. 

Where  several  fingers  are  implicated  it  is  advisable  to  separate  only 
two  of  them  at  a  time.  When  bones  have  been  chiseled,  the  surfaces 
may  be  covered  with  grafts.  There  is  a  tendency  to  contraction  of 
scar  bands  after  healing  along  the  suture  lines  or  grafted  areas,  and  for 
this  reason  systematic  massage  and  passive  motion,  together  with  the 
use  of  splints  at  night  over  a  period  of  months  is  important.  There  is 
often  a  tilting  of  the  terminal  phalanges,  especially  in  those  cases  in 
which  the  bones  are  fused.  This  can  be  gradually  overcome  by  the  use 
of  massage  and  splints. 

Webbing  of  the  fingers  which  may  be  as  varied  in  degree  as  the  con- 
genital variety,  are  encountered  after  severe  burns.  In  these  cases  the 
problem  is  complicated  by  the  presence  of  scar  tissue  which  adds 
greatly  to  our  difficulties. 

CONGENITAL  CONTRACTURES  OF  THE  FINGERS 

Congenital  contracture  of  the  fingers  is  apparently  not  so  rare  as 
was  formerly  thought.  It  occurs  principally  in  girls,  and  usually  in 
the  little  finger  of  one  or  both  hands.  It  may  occur  in  several  members 
of  the  same  family,  and  also  in  succeeding  generations.  I  have  in  mind 
the  case  of  twin  sisters,  in  each  of  whom  the  little  finger  of  both  hands 
was  congenitally  contracted.  In  this  family  there  had  been  no  previous 
history  of  a  similar  deformity  (Figs.  202-205). 

The  condition  is  usually  first  noticed  several  months  after  birth. 
Drooping  of  the  second  and  third  phalanges  of  the  little  finger  is  noted, 
but  there  is  no  indication  of  shortening  of  the  skin  or  involvement  of 
the  muscle  or  fascia,  and  the  finger  may  be  fully  extended.     The  de- 


246 


PLASTIC    SURGERY 


formity  in  this  stage  may  be  overcome  by  systematic  massage,  and  the 
proper  metal  retention  spHnt,  which  should  be  worn  for  several  months. 


Fig.  202. — Congenital  contracture  of  the  ring  and  middle  fingers  of  one  hand.  Male, 
aged  6  years. —  i.  The  limit  of  extension  before  operation  is  shown.  2.  The  amount  of 
extension  possible  after  liberation  of  all  binding  tissues  and  the  implantation  of  whole- 
thickness  grafts. 


Fig.  203. — Congenital  contracture  of  the  fingers  of  the  left  hand.  Male,  aged  20 
years. — Note  the  difference  in  the  extension  as  compared  with  the  other  hand.  In 
this  case  there  was  great  shortening  of  the  skin  and  underlying  tissues.  The  first  phalan- 
geal joint  surfaces  were  also  distorted  from  long  continued  flexion.  When  more  than  two 
fingers  are  involved  it  is  advisable  to  operate  on  only  one,  or  possibly  on  two  fingers,  at 
one  time. 


The  second  stage  shows  confirmed  contracture  with  hyperextension 
of  the  first  phalanx.  The  second  and  third  phalanges  are  flexed  in  the 
same  line,  more  or  less  rigidly  upon  the  first.     The  finger  cannot  be 


MALFORMATIONS 


247 


straightened  even  with  moderate  force.  There  is  no  evidence  of  mus- 
cular contracture,  but  in  most  cases  some  contracted  bands  of  fascia 
may  be  detected.  The  skin  also  seems  to  be  contracted,  and  the 
articular  ligaments  are  shortened  by  the  long  continued  flexion.  Later 
progressive  contracture  of  the  little  finger  is  likely  to  occur,  and  other 
fingers  may  also  be  implicated. 


Fig.   204. 


Fig.   205. 

Figs.  204  and  205. — Bilateral  congenital  contracture  of  the  little  fingers  in  twins. — 
I  and  I.  Note  amount  of  extension  in  both  little  fingers.  2  and  2.  Photographs  taken  si.x 
months  after  operation.  The  contracted  skin  bands  were  divided  by  Z-shaped  incisions. 
Then  the  ligaments  of  the  first  interphalangeal  joints  were  divided  as  far  from  the  joint  as 
possible,  and  the  skin  was  closed  after  straightening  the  fingers.  Perfect  function 
followed. 

The  contracture,  which  is  probably  primarily  due  to  thickening  of 
the  central  strip  of  the  digital  fascia,  is  aggravated  by  the  shrinkage  of 
the  skin,  and  the  gradual  shortening  of  muscles  and  articular  ligaments. 
In  the  old  cases  even  the  shape  of  the  joint  may  become  changed  and  in 
extreme  cases  amputation  of  the  little  finger  may  be  necessary. 


248  PLASTIC    SURGERY 

Treatment.- — Adams  advises  the  multiple  subcutaneous  division 
of  all  the  fascia  bands,  and  after  the  finger  has  been  straightened  the 
application  of  splints  continuously  for  several  weeks,  and  then  at  night 
for  several  months. 

In  attempting  to  straighten  some  of  these  deformities  I  have  some- 
times torn  the  skin  which  was  greatly  shortened  and  atrophied.  In 
such  cases  I  have  excised  the  entire  area  with  the  underlying  fascia,  and 
grafted  the  defect  with  Ollier-Thiersch  or  whole-thickness  skin  grafts, 
with  satisfactory  results. 

In  two  cases  I  have  used  the  Z-shaped  incision  for  the  skin,  excised 
the  fascia,  and  been  able  to  close  the  defect.  In  two  other  very  marked 
cases,  after  completing  the  above  procedure  I  was  unable  to  straighten 
the  finger  until  I  had  divided  the  anterior  and  lateral  ligaments  of  the 
first  interphalangeal  joint.  The  division  was  made  on  the  first  phalanx 
as  far  from  the  joint  as  possible.  By  using  this  procedure  I  was  able  to 
straighten  the  fingers,  whose  long  continued  contracted  position  pre- 
vented extension  by  other  methods.  It  might  be  necessary  in  cases  of 
long  duration  to  lengthen  a  tendon,  but  I  have  not  yet  found  this  pro- 
cedure necessary. 

Congenital  contractures  differ  from  the  Dupuytren  type  in  that  they 
are  congenital,  whereas  Dupuytren's  contraction  is  generally  a  disease 
of  adult  life;  congenital  contracture  usually  occurs  in  females,  whereas 
in  the  Dupuytren  variety  the  patients  are  most  commonly  men.  In 
the  congenital  form  the  central  portion  of  the  palmar  fascia  and  its 
lateral  prolongations  are  never  involved,  consequently  the  first  phalanx 
is  never  flexed,  but  is  hyperextended.  The  skin  is  atrophied,  but  is 
seldom  if  ever  indurated  and  lumpy,  a  condition  always  present  in 
Dupuytren's  contraction. 

HAMMER-TOE 

True  hammer-toe  is  essentially  an  hereditary  condition  (Adams). 
It  may  vary  in  extent  from  slight  inability  to  extend  the  second  or 
third  phalanges  of  the  toe  in  children,  to  dorsal  flexion  of  the  first 
phalanx  and  rigid  right-angled  flexion  of  the  second  phalanx  on  the 
first,  which  is  rarely  found  in  patients  under  15  years  of  age.  The 
third  phalanx  is  usually  on  the  same  line  as  the  second,  its  extremity 
resting  on  the  ground.  In  some  especially  severe  cases  the  third  pha- 
lanx is  rigidly  flexed  on  the  second,  and  the  dorsal  surface  of  the  nail 
rest  on  the  ground  (Fig.  206). 

Shattock  has  proved  that  the  deformity  is  due  to  contraction  of  the 


MALFORMATIONS 


249 


lateral  ligaments  of  the  joint,  or  joints  involved,  and  not  to  contraction 
of  the  flexor  tendons  or  plantar  fascia. 

In  the  old  cases  there  is  usually  an  extensive  painful  corn  over  the 
prominent   joint,    due   to   pressure   of   the   shoe;  when  infection  has 


Fig.  206. — Types  of  hammer-toe  (Adams). — i.  The  ordinary  type  of  hammer-toe 
with  rigid  flexion  of  the  second  phalanx  on  the  first.  2.  An  unusually  severe  form  of 
hammer-toe,  with  the  third  phalanx  flexed  on  the  second. 

occurred  and  the  joint  has  been  involved  there  may  also  be  destruc- 
tion of  the  joint,  and  bony  anchylosis  in  this  position.  The  second  toe 
is  usually  affected,  but  any  of  them  may  be  involved  to  a  lesser  degree. 


Fig.  207. — Operation  for  the  relief  of  hammer-toe  (R.Jones). — An  oval  piece  of  skin 
including  the  corn  is  excised  over  the  prominent  knuckle.  A  wedge,  base  upward,  suffi- 
ciently large  to  allow  straightening  of  the  toe  and  including  the  joint,  is  then  excised. 
The  flexor  tendon  is  divided,  and  the  wound  is  closed. 


Treatment. — Amputation  is  probably  the  most  common  method  of 
treatment,  but  this  should  be  regarded  as  a  last  resort.  The  flexor 
tendons  have  often  been  divided,  but  with  little  benefit.  In  cases 
without  bonv  anchvlosis  subcutaneous  division  of  the  contracted  lateral 


250  PLASTIC    SURGERY 

ligaments,  as  practised  by  Adams,  in  conjunction  with  the  use  of  the 
proper  corrective  apparatus  afterward,  is  often  sufhcient  to  relieve  the 
deformity. 

Various  methods  of  arthroplasty  (O'Neil  and  others)  have  been  tried 
with  some  success,  but  the  operations  are  complicated,  and  the  results 
are  no  better  than  those  obtained  by  simpler  methods. 

Through  lateral  or  dorsal  incisions  the  head  of  the  first  phalanx  has 
been  removed  (Wheeler),  and  the  toe  straightened.  The  articulating 
surfaces  of  both  bones  have  been  removed  through  similar  incisions, 
either  by  transverse  (Soule  and  others)  or  wedge  exsection  (R.  Jones) 
and  anchylosis  produced  in  the  extended  position  (Fig.  207). 

In  a  case  in  which  there  is  an  extensive  corn,  which  has  not  been 
removed  in  exposing  the  joint,  it  will  usually  be  found  that  there  is 
sufficient  relaxation  of  skin  after  reduction  of  the  deformity  to  allow  the 
excision  of  the  corn  and  suture  of  the  skin  edges. 

A  corrective  splint  should  be  used  for  some  time  in  the  shoe,  and  also 
at  night. 

The  results  are  good.  My  preference,  in  cases  without  joint  involve- 
ment, is  to  try  the  simple  method  of  division  of  the  lateral  ligaments  first, 
with  excision  of  the  corn.  In  the  more  extensive  cases,  excision  of  the 
head  of  the  proximal  phalanx,  or  a  wedge  exsection  of  the  joint,  should 
be  done. 

BIBLIOGRAPHY 

Angioma  and  Lymphangioma 

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Andrews,  E.  W.     "Surg.  Clin."     Chicago,  191 7,  i,  965. 

AuvRAY  &  Degrais.     "Bull,  et  mem.  Soc.  de  chir."     Paris,  1914,  n.  s.  59. 

Babcock,  \V.  W.     "New  York  Med.  Jour.,"  March  3,  191 7,  385. 

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CusHiNG,  H.     "Keen's  Surgery,"  iii,  27. 

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MALFORMATIONS  25 1 

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KiRMissox,  E.     "Bull.  acad.  de  med."     Paris,  1914,  3,s.  Lxxi,  849. 

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Lefevre.  W.  I.     "Ohio  State  Med.  Jour.,"  Dec,  1913. 
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Marchetti,  O.     "Riforma  med."     Xapoli,  igio,  xxvi,  1041. 

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Mitchell,  L.  J.     "Tr.  Ophth.  Soc.  U.  Kingdom."    London,  1911-12,  xxxii,  80. 

MoRESTix,  H.     "Bull,  et  mem.  soc.  de  chir.  de  Par.,"  191 2,  xxxviii,  1208. 

"Rev.  de  chir."     Paris,  1914,  xlLx,  137. 

"Bull,  et  mem.  soc.  de  chir.  de  Par.,'  1918,  694. 
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"Lancet."     London,  June  21,  1913. 
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"Journal-Lancet."     Minneapolis,  July  i,  191 7. 
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Pattox,  ^L  M.     "X'orthwest  Med."     Seattle,  1913,  n.  s.  v,  119. 
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Reder.  F.     "Surg.,  Gyne.  &  Obst.,"  July,  1915,  61. 

■'  Treatment  of   Cavernous  and  Plexiform  Angiomata  by  the  Injection  of  Boiling 
Water."     St.  Louis,  1918. 

Salomon,  A.     "Deut.  Zeit.  f.  Chir."    Leipsic,  May.  191 1,  cLx. 
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"Ergebnisse  d.  Chir.  u.  Orthop.."  Bd.  viii,  1914. 
Stromeyer,  K.     "Munchen  med.  Wchnschr.,"  Oct.  17,  1916,  1480. 
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Wrede.  L.     "Zent.  f.  Chir.,"  Xov.  19.  1910,  1496. 
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Polydactylism,  Syndactylism,  Contracttires 

Adams,  W.     "Contractions  of  the  Fingers,"  2d  Ed.,  1892,  95. 
Agxtew,  D.  H.     "Principles  and  Practice  of  Surgery,"  1883,  iii,  371. 

V.  Bergmaxx  (Bull).     "System  of  Practical  Surgery,"'  1904.  iii,  pp.  227,  270. 

BiDWELL.     "Minor  Surgery,"  2d  Ed.,  p.  90. 

BiESEXBERGER,  H.     " Beitrage  z.  klin.  Chir.,"  Bd.  88,  1914,  566. 

BixxiE.  J.  F.     "Manual  of  Operative  Surgery,  7th.  Ed.,  1150. 

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252  PLASTIC    SURGERY 

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Hammer -Toe 

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CHAPTER  XI 
HARELIP  AND  CLEFT  PALATE 

Xo  surgeon  who  has  had  much  experience  with  this  work  will  deny 
that  cases  of  harelip  and  cleft  palate  are  difficult  to  handle  properly. 
There  is  no  group  of  cases  referred  to  the  plastic  surgeon  in  which  good 
results  are  more  important,  or  in  which  bad  results  show  so  plainly. 

Harelip  and  cleft  palate  are  congenital  deformities,  due  to  the  failure 
of  union  of  the  embryonic  processes  entering  into  the  formation  of  the 
lip  and  palate. 

Incidence  of  Harelip  and  Cleft  Palate. — Harelip  is  more  frequently 
found  in  males  (^73  per  cent  in  my  series),  than  in  females.  The  left 
side  is  more  frequently  impHcated  (80  per  cent  in  my  series).  It  is 
said  to  occur  once  in  about  2400  infants.  Turnure  quotes  Hang's 
statistics  dealing  with  the  relative  proportion  of  the  t}'pes  of  harelip: 
simple  unilateral  harelip  without  bone  involvement,  25  per  cent; 
simple  bilateral  hareHp  without  bone  involvement,  3  per  cent;  com- 
plicated (bone  involvement)  unilateral  harelip,  49  per  cent;  complicated 
bilateral  harelip,  23  per  cent.  The  percentages  in  my  own  series  of 
cases  practically  coincide  with  these  figures. 

The  reason  for  the  failure  to  unite  is  not  definitely  known,  although 
a  number  of  theories  have  been  advanced  to  account  for  the  malforma- 
tion. Hereditary  tendency  is  found  in  from  15  to  20  per  cent  of  the 
cases,  in  my  series  in  19  per  cent.  Great  difference  in  the  ages  of  the 
parents  has  been  noted  as  a  cause  in  some  cases.  As  an  offset  to  this 
I  have  seen  a  number  of  cases  in  which  although  the  parents  were  be- 
tween 20  and  30  years  of  age  and  in  the  most  vigorous  health  (witli  no 
family  history  of  any  such  condition  on  either  side) ,  the  first  child  was 
terribly  deformed  by  a  complete  harelip  and  cleft  palate,  whereas  the 
children  born  subsequently  were  perfect. 

Amniotic  adhesions,  malnutrition  of  the  mother,  injury  early  in  the 
pregnancy,  which  is  not  sufficiently  severe  to  kill  the  fetus,  and  sj-philis, 
have  all  been  considered  possible  etiological  factors  and  must  be  borne 
in  mind.  I  have  seen  several  cases  of  harelip  with  cleft  palate  in  chil- 
dren with  definite  congenital  sj-philis,  but  do  not  consider  that  this 
infection  is  a  common  cause  of  the  deformity. 

253 


2  54  PLASTIC    SURGERY 

In  some  cases  of  harelip  and  cleft  palate  the  mother  eagerly  prof ers  a 
history  of  a  fall,  a  fright,  or  of  having  seen  someone  with  a  harelip 
during  the  pregnancy,  to  which  she  attributes  the  deformity.  In 
my  series  maternal  impressions  were  noted  in  9  per  cent  of  the  cases. 
The  majority  of  these  impressions  take  place  late  in  the  course  of  the 
pregnancy,  and  can  have  nothing  to  do  with  the  defect,  as  can  be  seen 
from  the  following  table  taken  from  Berry  &  Legg: 

"Fetal  Life. — Fourteenth  day.  Appearance  of  primitive  mouth 
or  stomatodeum.  Fifteenth  day.  Disappearance  of  bucco-pharyngeal 
membrane.  Third  week.  Mandibular  arch  of  either  side  formed; 
maxillary  processes  bud  out  from  mandibular  arches.  Fifth  week. 
Fron to-nasal  process  appears;  olfactory  pits  widely  separated  by  the 
primitive  nose;  globular  processes  appear.  Sixth  week.  Union  of 
lateral  nasal  with  maxillary  processes;  division  of  stomatodeum  into 
an  upper  cavity,  the  nose,  and  a  lower  cavity,  the  mouth.  Eighth  week. 
Union  of  the  three  portions  of  palate  commences  anteriorly;  completion 
of  upper  lip  by  fusion  of  the  globular  processes.  Tenth  week:  Comple- 
tion of  union  of  the  palate  segments,  the  uvula  being  the  last  to  be 
completed." 

Associated  Deformities. — It  is  rare  to  find  other  congenital  deformi- 
ties associated  with  harelip  and  cleft  palate,  but  I  have  seen  several 
cases  in  which  club  foot  was  also  present.  Cases  associated  with  poly- 
dactylism  and  V-shaped  notches  of  the  lower  lip  and  congenital  hernise 
have  been  reported. 

VARIETIES  OF  HARELIP 

A.  Incomplete  harelip,  in  which  the  fissure  does  not  extend  into 
the  nostril. 

B.  Complete  harelip,  in  which  the 
fissure  extends  into  the  nostril. 

C.  Median  harelip. 
1^                 ^L       "^'**' '                  A.  Incomplete  harelip  may  be  sub- 

-'>>^>'-    -     *'^im. Z\     divided  into  (i)  Single  {unilateral)  hare- 

i  2  lip.     The    nostril  may  or   may  not  be 

Fig.  2 08 .—Single  incomplete    widened.     The  palate  may  or  may  not 

harelip. — i.  Note  the  notch  m  the  lip  ,  -^  -^  _  -^ 

and  the  thinning  of  the  tissues  into    be  iuvolvcd.     (2)  DouUe  (bilateral)  hare- 

the  nostril.      2.   Result  of  operation.      /•,         rj^-i         „       4.   m  j.    u 

tip.     Ihe   nostrils  may  or  may  not  be 
widened  and  flattened.     The  palate  may  or  may  not  be  involved. 

B.  Complete  harelip  may  be  subdivided  into  (i)  Single  (unilat- 
eral) harelip.     The  nostril  is  always  widened  and  flattened.     This  form 


HARELIP  AND  CLEFT  PALATE 


255 


is  often  associated  with  cleft  palate.  (2)  Double  (bilateral)  harelip 
is  often  associated  with  cleft  palate.  The  nostrils  are  always  widened 
and  flattened.  (3)  Double  complete  and  incomplete  harelip.  Com- 
plete on  one  side,  incomplete  on  the  other.  It  may  or  may  not  be  asso- 
ciated with  cleft  palate. 


Fig.  209. — Incomplete  harelip,  right  side. — i.   Before  operation. — 2.   Result  of  operation. 
There  was  no  palate  involvement  in  this  patient. 


Fig.  210. — Complete  single  harelip  (left  side)  associated  with  complete  cleft  palate. — 
I  and  2.  Condition  before  operation.  Note  the  projection  of  the  intermaxillary  bone. 
The  lip  was  closed  over  the  projecting  bone  by  a  modified  Thompson  operation.  3.  Result 
eight  months  after  operation.      Note  the  nostril  and  the  length  of  the  lip. 


Fig.  211. — Double  incomplete  harelip  with  double  complete  cleft  palate. —  i.  The  skin 
between  the  top  of  the  cleft  and  the  nostril  was  thin,  and  had  to  be  excised.  2.  Taken  two 
and  a  half  years  after  repair  of  the  lip.  The  palate  had  been  successfully  closed  in  the 
interval. 


C.  Median  Harelip  (Rare). — This  may  vary  in  extent  from  a  simple 
notch  in  the  midline  to  a  fissure  involving  the  entire  lip  and  lower  portion 
of  the  septum. 


2^6 


PLASTIC  SURGERY 


VARIETIES  OF  CLEFT  PALATE 

A.  Incomplete  cleft  palate,  in  which  the  cleft  does  not  implicate 
the  alveolus. 

B.  Complete  cleft  palate,  in  which  the  cleft  implicates  the  hard 
and  soft  palates,  and  extends  through  the 
alveolus.  The  extent  of  the  cleft  varies  con- 
siderably. 

A.  Incomplete  cleft  palate  may  be  sub- 
divided into  (i)  Cleft  of  the  soft  palate  alone. 
Fig.  2I2.-A  single  incom-  ^Ms  may  implicate  only  the  uvula  or  the  en- 
piete   harelip.— The  margins  tire  soft  palate  may  be  cleft.     (2)  Cleft  of  the 

of  the  cleft  were  close  together    777  r  777  •        •         j 

and  were  easily  approximated,  hard  palate  as  Jar  as  the  alvcotar  margin,  m  ad- 
in  a  case  of  this  type  it  is  ad-  ^^^^  ^^   ^j^^  ^^n  palate.     The  extent  of  the 

visable  to  excise  the  thinned  _  ■'       ^ 

tissue  just  below  the  nostril  cleft   in   the   hard  palate  may  vary  from  a 

and  proceed  as  in  a  complete  ^   ^      •       ^^  .      •  .•  ^  •         t 

i^areiip.  notch  m  the  posterior  portion  to  one  impii- 


FiG.  213. — Complete  harelip;  right  side.  Cleft  of  the  alveolar  margin. — i.  Before  opera- 
tion. 2.  Pour  years  after  operation.  The  lip  is  very  satisfactory,  but  the  nostril  is  slightly 
lower  than  it  should  be.      There  was  no  palate  involvement  in  this  case. 

eating    three-fourths    of    the    entire  palate.     Occasionally  we  find  a 
definite  notch  or  even  separation  on  one  side  at  the  junction  of  the 


Fig.  214. — Complete  harelip  and  cleft  palate,  right  side. — i.  There  are  ten  children  in 
the  family,  the  second  and  tenth  had  harelip  and  cleft  palate.  Before  operation.  Note 
the  projecting  intermaxillary  bone.  2.  One  year  after  operation.  Too  much  allowance 
was  made  for  shrinkage  of  the  scar,  and  the  excess  of  projecting  vermillion  border  should  be 
removed  to  make  the  lip  perfect. 

intermaxillary  bone  with  the  maxilla,  without  malformation  of  the  hard 
or  soft  palate. 


HARELIP  AND  CLEFT  PALATE 


257 


B.  Complete  cleft  palate  may  be  subdivided  into  (i)  Single  {uni- 
lateral) clej't  palate,  which  is  usually  associated  with  a  complete  harelip 


Pig.  215. — Complete  harelip  and  cleft  palate,  left  side. — i.  Before  operation.  The 
intermaxillary  bone  on  the  left  side  projects  markedly.  2.  Two  weeks  after  operation. 
The  stitch  marks  will  gradually  disappear. 

on  the  same  side,  and  projecting  intermaxilla  on  that  side.     (2)  Double 
(bilateral)    cleft  palate.     This  is   usually   associated  with   a   complete 


Fig.  2x6. — Complete  harelip  and  cleft  palate,  on  the  right  side. — i.  Note  the  wide 
cleft  and  the  projecting  intermaxilla. — 2.  Taken  ten  days  after  operation.  The  lip  was 
closed  over  the  bone  without  reducing  it.  The  marks  of  the  stitches  can  still  be  seen. 
This  patient  returned  to  the  hospital  six  months  later  for  the  repair  of  the  palate.  The 
intermaxilla  had  during  this  time  practically  assumed  its  normal  position,  and  the  cleft 
had  narrowed  considerably,  thus  simplifying  the  operation. 

double  harelip,  the  entire  intermaxilla  projecting  forward  as  a  snout. 
In  the  group  involving  the  alveolus  the  extent  of  the  defect  in  the 


* 

Fig.  217. — Double  hareUp,  complete  on  the  left  side,  incomplete  on  the  right.  There 
is  also  complete  cleft  palate  on  the  left  side. — i.  Before  operation.  2.  Ten  days  after 
operation.  Note  the  projecting  teat  of  vermillion  border  in  the  midUne  to  counteract  the 
tendency  to  shrinkage. 

lip  may  vary  considerably  and  numerous  combinations  are  found.     In 
complete  cleft  palate,  either  single  or  double,  the  palate  defect  is  usually 


258 


PLASTIC    SX3RGERY 


in  or  close  to  the  midline,  back  of  the  attachment  of  the  intermaxillary 
bone.  The  nasal  septum  may  be  in  the  midline  unattached  to  the  edges 
of  the  cleft.  In  other  cases  it  may  be  attached  to  one  side  of  the  cleft, 
and  always  to  the  side  opposite  to  that  on  which  the  harelip  (if  it  be 
present)  is  situated. 


Pig.  2i8. — Double  complete  harelip  and  cleft  palate. — i.  The  intermaxilla  projected 
as  a  snout.  It  was  placed  in  proper  position  by  the  excision  of  a  wedge  of  the  cartilaginous 
septum  removed  submucously.  2.  Result  ten  days  later.  Note  the  stitch  marks  which  are 
still  present.     Also  the  nostrils,  the  length  of  the  upper  lip  and  the  absence  of  constriction. 

In  the  great  majority  of  instances  central  holes  in  the  palate  are 
due  to  disease  (syphilis,  tuberculosis,  typhoid  ulceration),  or  trauma, 
although  occasionally  the  defect  is  unquestionably  congenital  in  origin. 

Proper  Sequence  of  Operative  Procedures 

Some  surgeons  insist  that  the  palate  should  be  operated  on  before 
the  lip  in  all  cases  of  cleft  palate  associated  with  harelip,  since  they  claim 


1234 

Fig.  219. — Double  complete  harelip  and  cleft  palate. — i  and  2.  Note  the  width  of  the 
gap  and  the  snout  formation.  The  intermaxilla  was  replaced  by  the  submucous  removal  of 
a  wedge  of  the  septum,  and  the  lip  was  closed  by  a  modified  Thompson  operation.  3  and  4. 
The  result  one  month  after  operation.  Considerable  improvement  may  still  be  made  by 
secondary  operations.  Note  the  good  position  of  the  nostrils,  and  that  there  is  no  de- 
pression of  the  lip. 

that  the  gap  in  the  lip  gives  better  access  to  the  palate.  At  first  sight 
this  might  seem  reasonable,  but  in  actual  practice  the  closed  lip  seldom 
limits  the  exposure.  My  own  preference  for  closure  of  the  lip  first  is 
based  mainly  on  the  fact  that  in  the  majority  of  cases  the  constant  pull 
of  the  muscles  of  the  lip  will  cause  the  margins  of  the  cleft  in  the  alveolus 


HARELIP  AND  CLEFT  PALATE 


259 


and  palate  to  approach  each  other.  Blair  holds  that  this  occurs  in 
only  50  per  cent  of  cases,  but  so  far  as  my  experience  goes,  the  percent- 
age is  considerably  larger.  In  some  cases  spontaneous  closure  of  the 
alveolar  margin  will  be  caused  by  this  continuous  lateral  pressure,  and 
it  is  extraordinary  how  much  the  gap  in  the  hard  palate  can  be  narrowed 
in  this  way.  I  have  had  a  number  of  cases  of  complete  cleft  palate  with 
wide  single  alveolar  cleft,  associated  with  projecting  intermaxillary  bone, 
in  which  the  width  of  the  cleft  almost  precluded  the  possibility  of 
successful  closure.  After  restoration  of  the  lip  the  cleft  was  so  narrowed 
in  the  course  of  a  few  months  that  the  operative  procedure  for  closure 
of  the  palate  was  relatively  easy. 


Fig.  220. — Double  complete  harelip  and  cleft  palate. — i  and  2.  Note  the  width  of  the 
gap  and  the  marked  snout  formation.  The  condition  of  the  child  was  so  poor  that  the 
intermaxilla  was  replaced  and  held  in  position  by  wire  sutures  first,  and  several  months 
later  the  lip  was  closed.  3.  Taken  eight  months  after  closure  of  the  lip.  Secondary 
shaping  operations  must  be  done  to  obtain  the  desired  result.  The  mother  of  the  patient 
expressed  some  annoyance  when  she  found  that  a  scar  was  present  when  she  took  the 
child  home. 


Early  closure  of  the  lip,  has  of  course,  no  effect  on  the  width  of  the 
cleft  in  cases  of  incomplete  cleft  palate,  when  the  alveolar  margin  is 
not  effected.  In  these  cases  the  lip  should  be  closed  first  for  cosmetic 
reasons,  and  to  allow  nursing,  which  may  be  taught  in  some  cases. 

Time  of  Operation. — I  have  closed  double,  very  extensive  vTomplete 
harelips,  in  which  the  question  of  nourishment  was  a  matter  of  vital 
importaiice,  within  12  hours  after  birth,  but  prefer  to  wait  for  several 
weeks  (preferably  from  six  weeks  to  four  months).  If  a  child  cannot 
be  properly  nourished  a  chance  should  be  taken  even  if  the  physical 
condition  is  poor;  otherwise  it  is  advisable  to  wait  until  the  patient 
is  thriving.  This  point  I  consider  of  such  importance  that  I  sometimes 
keep  children  in  the  hospital  for  weeks  before  operating,  until  with  the 
help  of  a  skilled  pediatrist  the  desired  condition  has  been  brought  about. 
In  this  way  lives  are  certainly  saved,  and  I  attribute  my  very  low  mor- 
tality in  harelip  and  cleft  palate  cases  in  some  part  to  this  precaution. 
Blair,  Brophy,  Lane  and  a  few  other  surgeons  advocate  operating  on 


26o 


PLASTIC    SURGERY 


cases  of  cleft  palate  within  a  few  hours  after  birth.  My  experience  has 
been  that  it  is  better  to  wait  until  the  full  benefit  of  the  lip  closure  is 
obtained  and  the  cleft  is  narrowed  as  far  as  possible.  I  prefer  to  oper- 
ate when  the  child  is  from  eight  to  eighteen  months  old,  and  in  my 
series  the  results  have  seemed  to  justify  the  delay. 

Are  We  Justified  in  Operating  on  Adults  with  Harelip  or  Cleft 
Palate? — There  is  no  reason  whatever  why  these  older  patients  suffer- 
ing from  one  or  both  of  these  malformations  cannot  be  operated  on 
successfully.  Some  of  them  have  learned  to  speak  distinctly,  to  sing 
well,  and  to  eat  solid  food  without  difficulty.     A  successful  closure  of  the 


Fig.  221. — Method  of  narrowing  a  cleft  by  means  of  continuous  elastic  traction. 
(Sherman).  The  inner  end  of  the  plaster  is  placed  on  the  cheeks  just  outside  of  the  alae. 
The  outer  ends  extend  upward  and  outward  as  high  as  the  top  of  the  ear.  Note  the  hooks 
and  the  elastic  band  in  position. 

palate  in  these  cases  will  probably  cause  little  improvement  in  the  speech, 
but  closure  of  the  lip,  when  associated  with  a  complete  cleft  palate,  will 
transform  a  monstrosity  into  a  fairly  normal  looking  individual. 

Preliminary  Care.— Nutrition  should  be  brought  to  the  highest 
state.  The  child  should  become  accustomed  to  being  fed  from  a 
spoon,  medicine  dropper,  or  small  glass  syringe,  since  nursing,  either 
from  the  bottle  or  breast  should  not  be  allowed  for  at  least  ten  days 
after  the  operation.  In  older  children  adenoids,  tonsils,  and  decayed 
teeth  should  be  attended  to  before  an  operation  for  cleft  palate.  I  con- 
sider it  unwise  to  operate  if  the  hemoglobin  is  under  75  per  cent. 


HARELIP  AND  CLEFT  PALATE  261 

The  cleft  may  be  narrowed  somewhat,  while  awaiting  operation, 
by  drawing  the  margins  of  the  lip  tissure  toward  each  other,  and  hold- 
ing them  in  this  position  with  strips  of  adhesive  plaster  to  which  hooks 
are  attached,  so  that  continuous  elastic  traction  can  be  exerted  with 
small  rubber  bands  (Fig.  221).  For  several  days  before  operation  the 
throat  and  nose  should  be  sprayed  with  an  antiseptic  solution — Boul- 
ton's  solution- (one-half  strength),  Dobell's  solution  (one-third  strength), 
or  the  alkaline  antiseptic  solution  of  the  National  Formulary. 

The  urine  should  be  examined  especially  for  acetone  and  diacetic 
acid,  and  the  child  should  be  given  bicarbonate  of  soda  by  mouth  every 
4  hours  for  several  days  before  operation  as  a  precaution  against 
a  possible  acidosis. 

Anesthesia. — General  anesthesia  is  necessary  in  operating  for 
harelip  and  cleft  palate.  I  prefer  ether  given  as  heated  vapor,  either 
through  a  nose  tube  or  through  a  tube  in  the  mouth  gag.  Intra- 
tracheal anesthesia  in  older  children  is  of  great  benefit  and  eliminates 
the  danger  of  aspiration  pneumonia.  It  may  also  be  necessary  to  give 
a  primary  anesthetic  when  removing  the  sutures  from  the  palate. 

Position  During  Anesthesia. — Many  operators  prefer  to  have 
the  patient  held  in  a  sitting  position  during  the  operation  for  harehp 
and  cleft  palate.  My  preference  is  to  have  the  patient  lying  down 
with  the  head  supported  by  a  well-padded  circular  head-rest  attached 
to  the  table.  In  cleft  palate  operations  the  head  should  be  lowered  in 
the  Roser  position,  care  being  taken  to  support  its  weight  with  a 
padded  head-rest. 

Preparation  of  the  Part. — The  lip  and  adjacent  portions  of  the  face 
should  be  washed  with  ether  or  benzine,  and  then  painted  with  one- 
third  strength  tincture  of  iodin.  The  field  should  be  isolated  with 
properly  applied  sterile  drapings. 

TREATMENT  OF  HARELIP 

Points  to  be  Observed  in  All  Types  of  Harelip  Operations.— Ten- 
sion must  be  thoroughly  relieved  by  separating  the  lip,  cheek  and  nostril 
from  the  underlying  bone.  This  separation  is  most  conveniently 
effected  with  a  pair  of  curved  ]Mayo  scissors.  In  some  instances' it  is 
necessary  to  carry  the  undercutting  outward  under  the  cheek  for  a 
considerable  distance  in  order  that  the  edges  of  the  cleft  may  be  brought 
together  without  tension.  The  margins  must  be  freshened  in  such  a 
way  that  the  raw  surface  on  either  side  is  of  the  same  length  and  the  sur- 


262  PLASTIC    SURGERY 

faces  to  be  approximated  should  be  as  broad  as  possible.  The  de- 
nudation of  the  margins  of  the  tissues  should  be  planned  so  that  when 
the  suturing  is  done  the  sutured  line  will  be  slightly  longer  than  the 
length  of  the  lip  thus  allowing  for  subsequent  shrinkage.  This  must 
also  be  planned  for  in  cutting  the  vermilion  border  and  a  small  projecting 
teat  should  be  left  to  avoid  a  notch  after  healing  is  complete.  The 
parts  should  be  approximated  as  far  as  possible  in  their  normal  posi- 
tions, especially  the  muscle  elements.  This  has  an  important  bearing 
upon  the  restoration  of  motion  of  the  upper  lip.  Skin  should  be  sutured 
only  to  skin,  and  mucous  membrane  to  mucous  membrane,  as  unsightly 
defects  often  result  if  this  point  is  not  carefully  observed.  Every 
effort  should  be  made  to  bring  up  and  secure  in  place  the  flattened 
nostril,  so  that  it  will  resemble  its  normal  fellow.  When  the  edges  of  the 
fissure  are  thin,  the  skin  and  the  mucous  membrane  should  be  carefully 
split  and  spread  apart  without  removing  any  marginal  tissue,  except  at 
the  upper  and  lower  portions  of  the  fissure,  where  partial  excision  is 
necessary  in  order  to  make  the  desired  approximation.  In  this  way 
the  lip  at  the  sutured  line  can  be  considerably  thickened,  and  broad 
raw  surfaces  approximated.  Care  must  be  taken  that  the  lip  be  at 
least  long  enough  to  cover  the  gums  completely.  There  should  be  very 
little,  if  any,  tension  on  the  sutures,  and  any  blanching  of  the  tissues 
when  the  edges  are  approximated  means  that  the  sutures  are  tied  too 
tightly  or  that  the  tension  has  not  been  properly  relieved.  The  muco- 
cutaneous line  of  the  newly  formed  upper  lip  should  be  an  unbroken 
curve  from  one  side  of  the  mouth  to  the  other. 

It  is  unnecessary  to  apply  any  of  the  various  methods  devised 
for  relieving  tension  on  the  suture  line — adhesive  strips,  metal  springs, 
etc. — if  the  operation  is  properly  performed,  and  I  have  long  since 
abandoned  such  apparatus  without  regret. 

Hemorrhage,  which  is  quite  violent  immediately  after  denudation 
or  undercutting,  can  usually  be  controlled  by  packing,  or  properly 
applied  pressure.  Ligature  of  the  vessels  is  seldom  necessary.  There 
are  a  number  of  lip  clamps  on  the  market  which  are  placed  near  the 
corners  of  the  mouth  to  control  the  coronary  arteries,  but  none  of  them 
are  quite  satisfactory  and  one  soon  discards  them  as  unnecessary. 

Operations  for  Single  Incomplete  Harelip 

The  incisions  shown  in  the  operations  of  Malgaigne  or  Nelaton  are 
good,  and  these  incisions  may  be  modified  to  suit  conditions  (Figs. 
222  and  223). 


HARELIP  AND  CLEFT  PALATE 


263 


When  there  is  a  notch  in  the  lip  and  a  wide  nostril  on  that  side, 
C.  H.  Mayo  makes  a  horizontal  incision  across  the  floor  of  the  nostril, 
and  after  wide  undercutting  converts  it  into  a  vertical  wound  which  he 


Fig.  222. — Malgaigne's  operation  for  single  incomplete  harelip  (Binnie). — i.  The 
dark  lines  indicate  the  incisions  through  the  thickness  of  the  lip.  2.  The  flap  pulled  down- 
ward. The  edges  are  then  approximated,  skin  to  skin  and  mucous  membrane  to  mucous 
membrane.      The  excess  tissue  is  removed  from  the  free  ends  of  the  flaps. 

sutures.  In  this  way  the  notch  is  lowered  and  the  width  of  the  nostril 
is  reduced.  The  incision  extends  through  the  full  thickness  of  the  lip 
(Fig.  224). 


Fig.  223. — Operation  for  single  incomplete  harelip  (Nelaton). —  r.  The  dark  line 
indicates  the  incision  through  the  lip  parallel  to  the  notch  and  above  the  vermillion  border. 
2.  The  loop  of  tissue  drawn  downward.  3.  The  wound  closed  in  a  vertical  line.  Shrink- 
age of  the  scar  usually  reduces  the  apparent  over-correction. 

In  all  cases  of  incomplete  harelip  in  which  there  is  a  groove  to  the 
nostril  and  the  tissues  are  thin,  it  is  advisable  to  convert  the  defect 


Fig.  224. — C.  H.  Mayo's  operation  for  incomplete  harelip  {Binnie). — i.  The  dotted 
line  AB  indicates  the  transverse  incision  through  the  lip.  2.  Traction  is  made  on  the  mid- 
line of  the  lower  lip  of  the  wound,  and  the  edges  are  brought  together  vertically,  and  sutured. 

into  the  complete  variety  and  to  bring  thick  well-nourished  tissues 
together. 


264  PLASTIC    SURGERY 

Operations  for  Complete  Harelip 

The  diagrams  of  the  incisions  recommended  in  the  various  books 
on  surgery  are  in  many  instances  not  only  complicated,  but  for  the 
most  part  wrong  in  principle.  In  actual  practice  it  is  almost  impossible 
to  use  these  incisions,  if  we  wish  to  unite  the  tissues  which  normally 
should  be  in  apposition.  After  a  careful  study  of  the  various  methods 
extending  over  a  number  of  years  I  have  abandoned  all  the  complicated 
procedures  for  complete  or  nearly  complete  harelip  and  have  based 
my  procedures  upon  the  fundamental  principles  evolved  by  J.  E. 
Thompson  in  his  operation  for  single  or  double  harelip.  Of  course, 
Thompson's  operation  as  he  describes  it,  cannot  always  be  followed 
absolutely,  but  with  modifications  to  meet  the  conditions  it  has  proved 
itseK  by  far  the  simplest  and  most  eflBicient  for  general  use. 

G.  B.  Xew  has  recently  reported  the  procedure  used  at  the  ]\Iayo 
Clinic,  which  is  based  on  Thompson's  operation.  His  illustrations 
are  most  instructive  (Figs.  225  and  226). 

W.  E.  Ladd's  operation  which  I  have  found  useful,  is  also  based  on 
correct  measurements  of  the  denuding  incisions. 

Thompson's  Operation. — "i""  represents  a  case  of  single  complete 
hareHp.  For  purposes  of  convenience  the  red  line  of  the  Up  has  been 
represented  as  symmetrically  placed  on  each  side  of  the  cleft.  At  A 
and  A'  the  boundary  between  the  cleft  and  the  margin  of  the  nostril  is 
marked  by  a  sharp  projection  or  shoulder.  A  pair  of  sharp  pointed 
compasses,  regulated  with  a  screw  is  used,  and  a  measurement  {YZ) 
taken  from  the  level  of  the  opposed  corners  .4  and  A'  directly 
downward,  of  such  length  that  Z  would  lie  on  an  imaginary  line 
KL,  which  would  complete  the  natural  curi-e  of  the  upper  lip.  The 
points  of  the  compasses  are  now  fixed  apart  at  this  distance  {YZ)  and 
measurements  are  taken  in  the  hp  on  each  side  of  the  cleft  (shown  in 
2)  commencing  at  A  and  A'  respectively  and  passing  to  B  and  B'.  The 
points  B  and  B'  are  each  close  to  the  junction  of  the  skin  with  the  red 
line  of  mucous  membrane,  and  are  so  placed  that  AB  is  equal  in  length 
to  A'B'  and  each  one  is  the  same  length  as  YZ.  The  points  B  and  B' 
are  permanently  iLxed  by  pricking  the  skin  with  the  points  of  the  com- 
passes until  the  blood  appears. 

The  compasses  are  now  readjusted  and  a  measurement  BC  is  taken, 
the  point  C  being  on  the  free  margin  of  the  lip.  The  angle  which  BC 
makes  with  AB  is  usually  about  60°  but  varies  somewhat.  It  must 
always  be  less  than  90°.  if  a  projecting  prolabium  is  to  result  from  the 


HARELIP  AND  CLEFT  PALATE 


265 


silkworm. 


Fig.  225. — Operation  for  single  complete  harelip  (Neu-). — -.4.  The  calipers  deter- 
mining the  length  of  the  incisions  to  be  made.  The  dotted  lines  indicate  the  incisions  which 
terminate  at  the  vermilion  line  and  which  are  of  equal  length  on  each  side.  B.  The  muco- 
cutaneous margins  have  been  pared  and  the  lip  has  been  thoroughly  freed  from  the  bone 
on  each  side.  The  small  clamps  on  either  side  of  the  lip  are  to  control  bleeding.  C.  The 
first  silkworm  gut  suture  to  form  the  nostril  is  inserted  from  the  inside  and  does  not  pene- 
trate the  skin.  D.  The  first  silkworm  gut  suture  is  tied  and  the  second  is  placed.  E.  The 
skin  is  approximated  with  horsehair. 


266 


PLASTIC    SURGERY 


completed  operation.  A  similar  point  C  is  taken  on  the  other  side  of 
the  cleft.  Both  C  and  C  are  pricked  with  the  points  of  the  compasses. 
Being  now  ready  to  denude  the  sides  of  the  cleft  the  operator  passes  a 


F 


G 


^m 

m 

SixtiiTes 

H 

P, 

.^-'      of 

v^^ 

.,'' 

XoTSe- 

^^'' 

Kalr 

f^'; 

W ' 

. 

^ 

1 

Pig.  226. — Operation  for  harelip  (New). — F.  The  dotted  lines  on  the  vermilion 
border  indicate  approximately  the  incisions  made  to  complete  the  red  line  of  the  lip.  G. 
The  lip  completely  closed  with  horsehair  sutures. 

retaining  stitch  of  horsehair  through  each  side  of  the  mucous  membrane 
of  the  lip  close  to,  but  below,  C  and  C.  The  lip  is  transfixed  with  a 
narrow-bladed  knife  at  B,  and  the  knife  is  carried  with  a  sawing  sweep 
in  a  slight  curve  to  A,  where  it  emerges  exactly  at  the  shoulder.     The 


HARELIP    AND    CLEFT    PALATE 


267 


lip  is  then  divided  along  the  line  BC  and  the  tissue  outlined  by  ABC  is 
removed.  The  same  maneuver  is  carried  out  on  the  opposite  side  of 
the  cleft,  the  knife  passing  along  the  line  A'B'C'. 

As  a  result  we  now  have  two  raw  surfaces  opposed  to  one  another, 
the  corresponding  sides  of  which  are  equal  in  length.  Thus  AB  is 
equal  to  A'B',  and  BC  is  equal  to  B'C. 

If  A  be  united  to  A\  and  B  to  B',  and  C  to  C,  the  sides  of  the  wound 
between  these  points  can  be  brought  into  apposition  with  accuracy  and 
a  perfect  lip  will  result,  such  as  is  shown  diagrammatically  in  3. 

In  4  the  same  operation  is  shown  on  a  lip  in  which  the  sides 
of  the  cleft  are  divergent.     In  order  to  get  sufficient  depth  to  the  lip, 


(4)  <6) 

Pig.  227. — Diagrammatic  representation  of   Thompson's  operation   for  single  and  double 
harelip. — A  full  description  will  be  found  in  the  text. 


the  points  B  and  B'  will  necessarily  be  very  far  apart,  but  can  be  brought 
together  with  very  little  tension  if  the  cheeks  have  been  well  loosened 
beforehand.  Otherwise  the  steps  of  the  operation  are  identical  with 
those  shown  in  2  and  3. 

The  treatment  of  double  harelip  is  shown  in  5  and  6.  The  shoul- 
ders marking  the  margins  of  the  nostrils  are  shown  at  A  and  E,  and 
at  A'  and  £'.  The  triangle  E'DE  shows  the  line  of  incision  by  which 
the  central  piece  of  skin  covering  the  intermaxillary  bone  is  pared. 
E  and  E'  are  placed  on  the  inner  margins  of  the  nostrils.  The  sides 
DE  and  DE'  are  usually  equal  in  length  to  one  another,  and  their 
length  varies  according  to  the  depth  of  the  central  piece  of  skin.  It 
must  never  be  greater  than  AB  and  is  usually  much  less.  The  points 
A,  B  and  C,  and  A',  B\  and  C',  are  chosen  as  described  previously  in 
the  operation  on  single  harelip.  6  shows  the  final  appearance  of  the 
lip  when  the  flaps  have  been  cut  and  the  parts  approximated.     The 


268 


PLASTIC    SURGERY 


point  A  is  in  contact  with  E;  A'  with  E';  the  apex  D,  of  the  triangle 
E'DE,  hes  somewhere  along  the  line  AB]  the  point  B  is  in  contact  with 
5',  and  C  with  C  (Fig.  227). 

Two  essential  points  must  be  emphasized:  Under  no  circumstances 
must  the  circumference  of  the  nostril  be  encroached  upon.  The  shoul- 
ders that  represent  the  margins  of  the  nostril  must  be  accurately  approxi- 
mated. The  points  B  and  B'  must  be  as  close  to  the  red  line  of  the  lip 
as  possible,  and  must  always  be  on  the  skin  (upper  side)  of  this  line. 

The  various  parts  of  the  lip  resulting  from  this  method  of  operating 
are  reproduced  from  elements  normally  present.     They  are  free  from 


I  3  5 

Fig.  228. — Operation  for  double  harelip  in  cases  in  which  the  vermilion  border  cannot 
be  closed  {Lexer). — i.  Profile  in  double  harelip.  2.  The  vermilion  border  which  is  too 
short  to  be  sutured  together.  3.  A  flap  from  the  lower  edge  of  the  philtrum  is  turned 
down.  Outline  of  flap  A  of  mucosa  and  sub-mucosa  from  the  lower  lip.  4.  Showing  the 
flap  A  in  position  sutured  to  the  raw  surface  of  the  philtrum,  and  to  the  edges  of  the  ver- 
milion border.      5.   Result  after  cutting  the  pedicle  from  the  lower  lip  and  shaping. 

the  admixture  of  tissues  of  different  texture  and  consistence.  The 
nostril  is  formed  entirely  from  the  original  nostril  ring,  and  the  parts 
consisting  of  skin  and  mucous  membrane  from  skin  and  mucous  mem- 
brane alone. 

Symmetry  thus  results,  the  nostril  being  of  the  proper  size,  the 
cutaneous  portion  of  the  lip  of  the  right  depth,  the  mucous  membrane 
of  the  proper  width,  and  the  red  line  of  the  lip  running  from  side  to  side 
without  break  or  fault. 

Dr.  W.  E.  Ladd  has  devised  a  good  operative  method  which  is  appli- 
cable to  any  variety  of  single  harelip.  He  uses  two  pairs  of  split  angular 
clamps,  with  fine  teeth  to  prevent  the  skin  or  mucous  membrane  from 


HARELIP  AND  CLEFT  PALATE 


269 


slipping,  and  a  small  thin  double-edged  knife.  These  instruments  he 
employs  in  conjunction  with  an  ordinary  pair  of  small  sharp-pointed 
metal  dividers  (Fig.  229). 

The  distance  is  measured  from  the  septum  B  on  the  normal  nostril, 
and  from  the  edge  of  the  ala  {D)  on  the  cleft  side.  With  the  mouth 
closed  the  desired  height  of  the  lip,  minus  the  width  of  the  vermilion 
border,  is  determined  with  the  dividers.  This  distance  is  then  marked 
off  on  either  side  of  the  lip  by  pricking  with  the  sharp  ends  of  the 
dividers  at  the  points  A  and  B.  and  C  and  D,  which  are  to  form  the  lines 


m 


Fig.  229. — Ladd's  slotted  angled  clamps. — i.  Note  the  fine  teeth  in  the  jaws  of  the 
clamp,  and  also  the  screws  by  which  the  clamp  is  adjusted  as  snugly  as  desired.  2.  The 
slotted  angle  is  well  shown.  The  knife  is  inserted  in  this  slot  and  in  this  way  the  measured 
incisions  are  cut  with  absolute  accuracy. 


of  the  incision.  The  lip  and  cheek  are  then  freed  from  the  alveolar 
process  and  superior  maxilla  on  both  sides  until  the  edges  of  the  fissure 
can  be  drawn  together  without  tension.  The  clamps  are  then  applied 
— the  angles  of  the  slits  being  at  the  points  A  and  C — and  the  slits  are 
directed  toward  the  points  B  and  D.  The  lower  puncture  points 
should  be  in  the  center  of  the  angles.  The  knife  is  now  introduced  into 
the  slit  in  the  clamp,  carried  upward  to  the  nose,  and  downward 
through  the  border  of  the  lip,  making  the  incisions  BAE  and  DCF. 
The  clamps  are  now  removed,  and,  when  necessary,  are  reapplied  near 
the  corners  of  the  mouth  to  control  hemorrhage,  but  should  not  be 
kept  on  long  enough  to  cause  edema. 


270 


PLASTIC    SURGERY 


The  edges  of  the  two  incisions,  which  of  necessity  must  be  clean  cut, 
of  equal  length  and  consequently  fitting  each  other,  can  now  be  easily 
approximated,  bringing  the  points  B  to  D,  A  to  C,  and  E  to  F.  This 
is  done  with  one  row  of  interrupted  silk  stitches,  which  include  all 
layers  but  the  skin  and  are  tied  inside  the  lip.  A  subcuticular  suture 
of  fine  silk  is  used  for  the  skin  and  is  placed  as  follows:  A  perforated 
shot  having  been  attached  to  one  end,  the  silk  is  carried  on  a  straight 
intestinal  needle  from  the  outside  of  the  ala  to  the  edge  of  the  skin 
wound.  The  thread  is  then  drawn  through  and  the  shot  is  brought 
against  the  ala,  thus  holding  it  in  position.  The  silk  is  then  threaded 
on  a  small  curved  needle  and  a  subcuticular  suture  is  inserted  down 
the  lip  from  above,  to  the  vermilion  border,  where  it  is  tied  to  an  in- 
terrupted suture  which  closes  the  vermilion  line.     No  dressing  is  ap- 


FiG.  230. — Operation  for  single  complete  harelip  {W.  E.  Ladd). — i.  The  dotted  lines 
indicate  the  incisions.  The  line  AE  is  which  the  desired  height  of  the  lip  minus  the  width 
of  the  vermilion  border,  is  pricked  with  dividers,  and  DC  on  the  opposite  side  is  made  the 
same  length.  The  lines  AE  and  FC  across  the  vermilion  border  are  of  equal  length.  The 
angled  clamp  is  then  applied,  the  points  A  and  C  being  in  the  center  of  the  angle.  Then  the 
tissue  inside  the  dotted  lines  is  removed  by  incisions  along  the  slots  of  the  clamps.  2.  The 
edges  which  are  of  exactly  the  same  length  are  approximated.  3.  The  dotted  line  indi- 
cates the  fine  silk  subcuticular  suture  held  by  a  perforated  shot  at  the  edge  of  the  ala  and 
tied  at  the  vermilion  border  to  an  interrupted  suture  at  K. 


plied.  The  deep  inside  sutures  are  removed  in  ten  days;  the  subcu- 
ticular suture  in  from  seven  to  ten  days  (Fig.  230). 

I  have  seen  Dr.  Ladd  operate  on  several  cases  by  this  method,  and 
have  also  witnessed  his  excellent  results.  In  my  own  hands  this  method 
has  proved  satisfactory. 

Method  of  Suturing. — I  use  horsehair  with  a  half  curved  corneal 
needle  for  closing  the  lip  and  vermilion  border,  and  fine  silk  (which  may 
be  waxed)  for  the  mucous  membrane.  The  on-end  mattress  suture 
is  the  best  for  the  purpose.  It  is  so  placed  that  it  includes  a  good  bite 
of  the  lip  tissue  (muscle)  down  to,  but  not  including  the  mucous  mem- 
brane. This  suture  prevents  a  depressed  scar  and  by  its  use,  suture 
of  the  mucous  membrane  high  up  under  the  lip  is  made  unnecessary 


HARELIP  AND  CLEFT  PALATE 


271 


The  first  suture  which  is  carried  well  back  into  the  deep  tissues  below 
the  ala  is  placed  just  within  the  nostril,  and  should  round  it  in  good 
position,  but  not  encroach  upon  its  size.     Several  special  sutures  for 


Fig.  231. — Suture  to  correct  the  flattened  nostril  (Roberts). — i.  The  silver  wire  suture 
in  place.  2.  The  pared  edges  of  the  nostril  brought  together  and  the  suture  secured  by- 
perforated  shot. 

the  formation  of  the  nostril  have  been  evolved  and  are  shown  in  the 
diagrams.  The  second  suture  is  placed  at  the  junction  of  the  skin 
and  vermilion  border  and  subsequently  the  rest  of  the  incision  is  closed. 
If  necessary  a  few  very  superficial  interrupted  sutures  may  be  placed 


Fig.  232. — Method  of  inserting  the  stitch  to  shape  the  nostril  {Berry  and  Legg). — 
I.  After  the  edges  have  been  pared  the  stitch  is  passed  deeply  from  within  the  ala  and  is 
made  to  emerge  at  the  upper  part  of  the  raw  surface  of  the  lip  close  to  the  nostril.  2.  It 
is  then  carried  across  and  inserted  in  a  corresponding  place  on  the  raw  surface  of  the  nostril 
side  of  the  cleft.  It  is  inserted  as  deeply  and  as  close  to  the  cartilage  of  the  septum  as  possi- 
ble, and  emerges  inside  the  nostril. 

between  the  on-end  mattress  sutures.     The  use  of  horsehair  prevents 

unnecessary  scarring.     Two  or  three  silk  stitches  should  be  placed  in 

the  mucous  membrane  of  the  lower  half  of  the  lip  (Figs.  231  and  232). 

Silver  wire  or  silkworm  gut  held  by  perforated  shot  may  be  used  to 


272  PLASTIC    SURGERY 

shape  the  nostrils,  especially  in  cases  of  double  harelip.  If  tissues  are 
properly  mobilized,  there  is  no  need  for  tension  sutures  which  always 
leave  scars. 

The  superficial  sutures  may  be  removed  within  two  or  three  days; 
the  deeper  ones  gradually,  until  they  are  all  out  by  the  seventh  or 
eighth  day.  The  sutures  in  the  mucous  membrane  which  do  not  slough 
out  should  be  removed. 

Dressings. — No  dressings  are  necessary.  I  usually  paint  the 
sutured  line  with  one-third  strength  tincture  of  iodin,  and  over  this 
apply  compound  tincture  of  benzoin  evaporated  to  a  syrupy  consist- 
ency.    Occasionally  I  use  a  little  calomel  powder  on  the  suture  line. 

It  is  sometimes  advantageous  to  insert  split  rubber  tubes  of  suitable 
size  into  the  nostrils  to  prevent  collapse.  These  may  be  removed  after 
two  or  three  days.  Blair  has  suggested  the  use  of  a  rubber  tube  in  the 
mouth  (secured  by  tapes)  for  several  days  to  facilitate  breathing  until 
the  patient  becomes  accustomed  to  breathe  normally.  It  should  be 
removed  twice  a  day  for  cleansing,  and  feedings  may  be  given  through  it. 

The  Treatment  of  a  Prominent  Intermaxillary  Process 

In  a  child  with  a  single  complete  harelip  and  cleft  palate  with  a  pro- 
jecting intermaxilla,  an  attempt  should  be  made  to  push  the  bone  into 
place  with  the  fingers,  but  this  is  seldom  successful. 


Pig.  233. — Methods  of  dealing  with  prominent  intermaxillary  bones. — i.  The  projecting 
portion  should  be  pushed  back  into  alignment.  If  this  is  not  possible,  sometimes  the  bone 
is  partly  divided  at  A.  The  two  wire  sutures  are  preferable  to  one  long  mattress  suture,  as 
they  are  easier  to  remove.  2.  In  dealing  with  a  prominent  intermaxilla  after  reducing  it 
I  have  found  silver  wires,  placed  as  shown,  an  excellent  method  of  holding  it  in  position. 

Some  operators  chisel  partly  through  or  crush  the  bone  with  forceps 
at  the  junction  of  the  maxilla  with  the  intermaxillary  bone,  in  this  way 
reducing  it  by  partial  fracture  (Fig.  233).     This  is  bad  practice  and  in 


HARELIP    AND    CLEFT    PALATE 


273 


the  vast  majority  of  cases  unnecessar}'.  After  proper  undercutting 
the  lip  can  be  closed  over  the  bone  and  in  due  time  will  gradually  re- 
store it  to  the  desired  position. 

In  double  complete  harelip  and  cleft  palate,  with  a  projecting 
intermaxilla,  it  is  essential  never  to  remove  the  bone.  If  the  prominence 
is  not  too  pronounced  it  may  be  possible  to  close  the  lip  over  it.  If  it 
projects  as  a  snout  and  closure  is  impossible,  some  method  must  be 
used  to  bring  it  back,  so  that  the  soft  parts  may  be  closed  over  it.  In  a 
few  cases  this  may  be  effected  by  pressure,  but  this  method  invariably 
causes  a  deflection  of  the  septum  unless  there  is  a  fracture,  in  which 
case  the  reduction  can  easilv  be  made. 


Fig.  234. — Double  harelip  and  cleft  palate,  with  projecting  intermaxilla  (Berry  and 
Legg). — The  dotted  line  indicates  the  incision  made  for  the  submucous  removal  of  a  weige- 
shaped  portion  of  the  cartilaginous  septum.  After  removal  of  this  wedge  the  intermaxilla 
can  be  easily  restored  to  its  normal  position. 

A  wedge-shaped  piece  of  cartilaginous  septum  may  be  removed 
submucously  with  bone  scissors  after  the  mucosa  of  the  septum  on 
each  side  has  been  raised  through  an  incision  about  2.  cm.  (fr^  inch)  long 
made  in  the  free  margin  of  the  septum  behind  its  attachment  to  the 
intermaxilla  (Fig.  234).  Tilting  of  the  incisor  teeth  backward  should 
be  avoided,  but  provided  that  the  wedge  is  not  too  wide  or  too  high, 
there  is  little  danger  of  this  accident.  In  other  words,  as  little  of  the 
septum  should  be  removed  as  will  allow  of  proper  reduction.  Xo 
sutures  are  necessary  to  close  the  incision. 

Another  method  is  to  divide  the  septum  obliquely  after  separating 
the  mucosa,  so  that  reduction  of  the  intermaxilla  will  slide  one  part 
over  the  other. 

18 


2  74 


PLASTIC    SURGERY 


Quadrilateral  sections  of  the  septum  may  be  removed  for  the  same 
purpose,  and  are  said  to  prevent  tilting  back  of  the  incisor  teeth  (Doyen, 
Turnure) . 

Reich  has  devised  an  ingenious  method  which  prevents  the  tilting 
back  of  the  teeth.  He  dissects  the  philtrum  from  the  intermaxillary 
bone,  and  after  exposing  the  cartilaginous  septum  divides  it  upward 
and  backward  as  far  as  possible.  Next,  through  parallel  incisions  in 
the  posterior  portion  of  the  septum  he  separates  the  mucoperiosteum 
on  each  side  and  excises  a  triangle.  The  intermaxillary  bone  is  then 
pushed  back  into  position  (Fig.  235). 

It  is  advisable  to  denude  the  surfaces  of  the  intermaxilla  and  max- 
illary processes  where  they  come  in  contact. 


A  B 

Pig.  235. — Reich's  operation  for  repression  of  the  intermaxilla  (Binnie). — A.  i. 
Point  of  nose.  2.  Philtrum.  3.  Intermaxillary  bone.  4.  Oblique  section  of  the  septum. 
5.  Wedge  of  septum  to  be  removed.  B.  Shows  the  position  of  parts  after  removal  of  septal 
wedge  and  adjustment  of  parts. 

The  intermaxillary  bone  should  be  held  in  position  after  reduction, 
and  this  is  best  accomplished  by  means  of  silver  wire  placed  as  shown 
in  the  diagram.  It  is  better  to  use  two  pieces  of  wire  because  it  is  often 
very  difficult  to  remove  the  long  mattress  suture  which  soon  buries 
itself.  This  suture  may  be  removed  in  two  but  preferably  in  three 
weeks. 

In  one  or  two  cases  of  complete  double  harelip  and  cleft  palate  with 
the  snout  projection,  when  the  patient  was  unable  to  stand  the  com- 
plete lip  operation,  I  have  reduced  the  intermaxilla  by  taking  out  a 
small  wedge  of  the  septum  first,  and  later  when  the  condition  was 
improved  have  closed  the  lip. 

Complications  in  Harelip 

The  stitches  may  tear  out  on  account  of  too  much  tension,  or  fol- 
lowing an  infection,  or  the  child  may  tear  them  out  if  the  hands  are  not 


HARELIP    AND    CLEFT   PALATE 


275 


secured.  Stitches  may  be  removed  too  early  and  the  edges  of  the 
wound  separate.  I  have  had  one  death  from  pneumonia.  In  the 
series  of  cases  at  the  Johns  Hopkins  Hospital  I  note  deaths  from  hemor- 
rhage at  the  time  of  operation,  and  from  post-operative  bronchitis, 
pyelitis,  and  status  lymphaticus.  Acidosis  must  be  thought  of,  as 
it  occurred  in  a  number  of  my  cases  in 
spite  of  every  ordinary  precaution,  and 
in  one  or  two  cases  the  patient  was  des- 
perately ill. 

Hemophilia  must  also  be  borne  in 
mind  when  considering  operative  pro- 
cedures for  these  cases.  I  have  had  two 
cases  (one  of  harelip  and  one  of  cleft 
palate),  in  which  this  condition  existed, 
but  I  was  unaware  of  it  until  I  was  in 
the  midst  of  the  operation.  The  patient 
with  the  harelip  bled  for  several  days 
from  the  suture  line  and  stitch  holes,  but 
linally  recovered.  The  child  with  the 
cleft  palate  almost  bled  to  death  from 
post-operative  hemorrhage.  The  hemor- 
rhage was  linally  controlled  by  removal  of  all  the  stitches,  packing  with 
adrenalin  gauze,  and  the  application  of  digital  pressure  for  24  hours 
continuously.     Horse  serum  was  also  given  subcutaneously  in  this  case. 

Post-operative  Care.  — The   child  should  be  placed  on  a  Bradford 
frame  if  there  is  any  difficulty  in  controlling  it.     The   hands  should 


Pig.  236. — Method  of  adjust- 
ing the  vermilion  line  by  means  of 
a  Z-shaped  incision  (Berry  and  Legg). 
■ — -The  black  line  indicates  the  in- 
cision. The  dotted  lines  indicate 
the  area  trimmed.  The  flap  i  is 
superimposed  on  the  flap  2. 


Fig.    237. — Defective  result   of    an   old   harelip    operation. — i.  Before   operation.     Note 
the  irregular  vermilion  line  and  the  depressed  broad  lip  scar.      2.   After  operation. 

be  secured  so  that  the  fingers  cannot  be  placed  in  the  mouth.  This 
can  be  done  by  tying  the  hands,  or  by  the  use  of  stiff  cuffs  over  the 
elbow,  which  hold  the  arms  straight.  Should  the  child  be  restless, 
small  doses  of  paregoric  may  be  given.  Every  effort  should  be  made 
to  keep  the  patient  comfortable  and  from  crying. 


276 


PLASTIC    SURGERY 


As  a  routine,  if  the  child  is  old  enough,  water  containing  soda  bicar- 
bonate and  lactose  should  be  given  (per  rectum)  by  the  Murphy  drop 
method  for  the  first  24  hours.  Sterile  water  may  be  given  by  mouth 
every  two  or  three  hours  for  the  first  12  hours,  and  then  any  sterile 
liquid.  Soft  diet  may  be  started  after  a  week.  A  mild  cathartic 
should  be  given  as  needed. 


Pig.  238. — Defective  result  of  an  old  harelip  operation. — i.  Note  the  broken  alignment 
of  the  vermilion  border.  2.  Result  of  operation.  The  lip  operation  had  to  be  done  over 
completely.      There  was  also  a  complete  unilateral  cleft  palate  in  this  case. 

It  is  advisable  to  keep  the  mouth  clean  with  normal  salt  or  boric- 
acid  solution  swabs,  and  an  antiseptic  spray.  The  sutured  area  should 
be  kept  as  clean  as  possible.  Should  the  nostril  or  stitch  holes  become 
clogged  with  secretions  the  free  use  of  sterile  boric  ointment  will  soon 
soften  the  mass,  which  can  then  be  removed  with  a  cotton  swab.  Nurs- 
ing from  a  bottle  with  a  nipple  with  large  holes  in  it  can  be  taught, 


Pig.  239. — Bad  result  of  harelip  operation.  Duration  ten  years. — i.  Note  the  deep 
grooved  scar  and  the  break  and  notch  in  the  vermilion  border.  2.  Photograph  taken  one 
year  later.      Note  the  condition  of  the  nostril,  the  lip  scar,  and  the  vermilion  border. 

even  if  the  palate  is  not  closed,  but  this  should  not  be  started  until  ten 
days  after  the  operation. 


Secondary  Operations  for  Harelip 

Secondary  operations  for  harelip  are  required  in  many  cases  for. the 
correction  of  deformities  resulting  from  imperfect  primary  operations 


HARELIP  AND  CLEFT  PALATE 


277 


and  from  accidental  happenings,  among  which  are  the  cutting  out  of 
sutures,  and  infection.  Should  a  secondary  operation  be  necessary,  it 
should  never  be  undertaken  until  healing  is  complete  and  all  signs  of 
infection  have  disappeared. 

It  is  sometimes  advisable  to  do  slight  secondary  trimming  operations 
on  the  margin  of  the  lip  to  improve  the  appearance  after  a  primary 


)     U    ^)     ^ 


Fig.  240. — Method  of  correcting  a  notch  in  the  center  of  the  lip  following  an  operation 
or  double  harelip  {Berry  and  Legg). — i.  The  line  AB  represents  the  junction  of  the  skin 
margins.  The  shaded  area  CBD  the  mucous  membrane  drawn  up  at  the  point  B.  2.  The 
black  lines  indicate  the  incisions  made  through  the  lip  to  remove  a  diamond-shaped  area  of 
tissue.  3.  The  points  E  and  P  are  approximated  and  sutured,  thus  lowering  the  central 
portion  of  the  lip. 

operation  which  has  otherwise  been  quite  perfect.     In  some  cases  the 
nostril  may  also  have  to  be  raised. 

In  single  harelip  the  entire  line  of  union  may  be  involved.  Thus, 
the  scar  may  be  wide  and  unsightly,  and  the  tissues  thin  owing  to 
incomplete  union  of  the  muscular  tissue  of  the  lip,  or  the  two  sides  of  the 
lip  may  have  been  sutured  so  that  they  are  out  of  alignment,  one  being 


Fig.  241. — Types  of  bad  results  following  harelip  operations. — -r.  Note  the  prominence 
of  the  philtrum  and  the  hitching  up  of  the  vermilion  border.  2.  The  result  of  removal  of 
the  intermaxilla.  3.  Note  the  closure  of  the  nostrils.  All  of  these  cases  were  operated  on 
elsewhere.  All  were  the  result  of  operations  for  double  complete  harelip  with  cleft 
palate. 

on  a  higher  level  than  the  other.  In  both  of  these  cases  the  nostril  is 
usually  flattened.  The  only  rational  method  of  procedure  is  to  excise 
the  scar  completely  and  perform  the  operation  as  if  it  were  the  primary 
one.  It  is  always  more  difficult  to  secure  a  satisfactory  result  in  these 
cases  than  in  one  which  has  not  been  previously  operated  on. 


PLASTIC    SURGERY 


Only  a  portion  of  the  line  of  union  may  be  defective,  the  rest  being 
satisfactory:  either  the  upper  portion  close  to  the  nose,  in  which  case 
the  nostril  is  usually  flattened,  or  the  lower  portion  of  the  lip  mav  need 
attention. 

When  only  a  portion  of  the  lip  is  involved,  correction  may  be  made 
by  excision  of  the  defective  portion  only,  coupled  vnth  the  necessary 
trimming  and  closure,  without  any  disturbance  of  the  portion  correctly 
repaired. 

In  double  harelip  we  may  have  conditions  similar  to  those  described 
for  single  harelip.  But  in  addition  it  is  sometimes 
diflicult  to  close  the  soft  parts  without  a  certain  de- 
gree of  tension,  even  after  the  intermaxillary  bones 
have  been  replaced.     In  these  cases  there  may  be  a 


Fig.  242.  Fig.  243. 

Fig.  242. — Apparent  prominence  of  the  lower  lip  due  to  defective  alveolar  margin  in  a 
case  of  cleft  palate,  i.  The  lip  and  palate  have  been  closed.  2.  Excess  tissue  has  been 
removed  from  the  lower  lip  both  transversely  and  laterally.  This  patient  is  now  under  the 
care  of  an  orthodontic  surgeon  who  ■will  be  able  to  bring  forward  the  alveolar  margin  to  a 
certain  extent,  and  thus  further  improve  the  appearance. 

Fig.  243. — Projecting  philtrum  following  an  operation  for  complete  double  harelip  and 
cleft  palate,  i.  Note  the  projection  between  the  columna  a^d  the  vermilion  line.  2. 
Result  of  operation.  Excess  tissue  was  removed  and  in  this  instance  an  inclusion  cyst 
about  the  size  of  a  marrow-fat  pea  was  found.  I  have  never  before  encountered  a  similar 
cyst  in  a  case  of  this  kind. 


separation  of  the  margin  of  the  lip  at  the  midline,  or  a  triangular  area 
of  mucous  membrane  may  extend  in  this  region  above  the  normal  line. 
Another  deformity  is  due  primarily  to  the  prominent  intermaxilla. 
The  philtrum  may  project  forward  causing  a  button-shaped  deformity 
although  there  may  be  no  opening  in  the  suture  line;  or  the  line  may  be 
broken  and  the  intermaxilla  project  through  its  upper  part,  causing  a 
fistula  through  the  lip. 

In  double  harelip,  after  reduction  of  the  intermaxilla  and  closure, 
the  lip  is  usually  quite  tight  and  relatively  the  lower  lip  projects.  This 
is  most  marked,  of  course,  in  those  cases  in  which  the  intermaxillarv 


HARELIP  AND  CLEFT  PALATE 


279 


bones  have  been  removed.  This  flatness  of  the  upper  lip  has  given  me 
much  trouble,  and  I  have  not  yet  been  able  to  overcome  it  to  my  entire 
satisfaction.  I  have  removed  portions  of  the  lower  lip  in  some  cases  to 
fnake  the  relative  projection  seem  less  pronounced.  Abbe's  method 
of  inserting  a  pedunculated  flap  from  the  lower  lip  to  give  greater  length 
to  the  upper  lip  and,  at  the  same  time  reducing  the  size  of  the  lower 
lip,  is  valuable  (Fig.  244).  The  best  results  are  obtained  by  referring 
such  cases  to  the  orthodontic  surgeon,  who  is  able  to  realign  the  alve- 
olar margin  and  bring  the  upper  jaw  out  to  its  proper  position.  Then, 
after  this  is  done,  the  plastic  surgeon  can  correct  any  minor  external 
defects  by  secondary  operations.  It  has  been  suggested  that  cartilage 
or  bone,  or  fat  transplants,  paraffin  injections,  and  other  methods. 


.'  V. 


Fig.  244. — Operation  for  widening  the  upper  lip  (Abbe). — ^i.  A  median  vertical  inci- 
sion is  made  in  the  upper  lip.  and  the  scar  is  excised.  The  dotted  line  on  the  lower  lip 
indicates  the  outline  of  the  flap  through  the  thickness  of  the  lip.  the  pedicle  being  at  the 
point  B.  2.  The  flap  is  turned  upward  and  is  sutured  accurately  into  the  gap  in  the  upper 
lip.  The  chin  wound  is  closed.  The  lips  are  held  together  by  necessary  retraction  sutures 
and  food  is  given  through  the  nares.     3.   The  pedicle  is  cut  and  fitted  after  twelve  days. 

might  be  used  to  overcome  the  flattening  of  the  upper  lip,  but  none  are 
as  rational  as  the  one  just  mentioned. 

Secondary  operation  on  double  harelips  are  likely  to  be  very  exten- 
sive and  very  difficult.  The  cooperation  of  the  orthodontic  with  the 
plastic  surgeon  is  most  essential  in  these  cases. 

THE  TREATMENT  OF  CLEFT  P.ALATE 

The  parents  must  be  impressed  with  the  fact  that  the  operation 
for  cleft  palate  is  a  serious  one.  There  is  usually  considerable  loss  of 
blood.  The  operation  is  often  of  long  duration — two  hours  not  being 
excessive  in  some  cases — and  post-operative  complications  may  occur. 

The  factors  of  the  greatest  importance  to  be  considered  in  the  repair 
of  a  cleft  palate  are  (i)  the  height  of  the  palatine  arch;  (2)  the  amount 
of  soft  tissue  (mucoperiosteum)  between  the  alveolar  border  on  each 


28o 


PLASTIC    SURGERY 


side  and  the  margin  of  the  cleft;  (3)  the  comparative  width  of  the  cleft. 
Naturally,  the  higher  the  arch  and  the  narrower  the  cleft,  the  easier 
it  is  to  close  the  defect. 

In  making  a  flap  every  effort  should  be  made  to  preserve  a  blood 
supply  sufficient  to  nourish  it.     The  nerve  supply  and  the  musculature 


B'CQ-TucKss  "to 
soft    "go-late 
(XT^a.  ton.  si  I 


BTauch.     aiv-CLStoTaoslTv^ 
with,    ascen-dlin^    palati-Tve  a. 


Fig.  245. — Blood  supply  of  the  palate  (New). — Note  the  relationship  of  the  great 
palatine  artery  of  the  alveolar  process,  also  its  branches  to  the  soft  palate.  Every  effort 
should  be  made  to  avoid  injury  to  the  artery  when  making  relaxation  incisions  and  when 
raising  the  mucoperiosteal  flaps. 


of  the  soft  palate  should  not  be  disturbed  unnecessarily.  The  healing 
should  be  as  free  from  inflammatory  reaction  as  possible,  as  a  soft, 
pliable  velum  is  most  important  for  good  subsequent  articulation. 

After  trying  various  methods  of  closing  cleft  palates,  I  have  reached 


HAliELIP    AND    CLEFT    PALATE 


281 


the  conclusion  that  the  edge-to-edge  approximation  based  on  Langen- 
beck's  operation,  is  the  method  of  choice.  In  suitable  cases  it  can  be 
employed  in  conjunction  with  the  flap  method  advocated  by  Lane. 
In  looking  over  the  cleft  palate  cases  at  the  Johns  Hopkins  Hospital 
I  find  that  at  least  60  per  cent  of  the  operations  have  been  done  by  the 
Langenbeck  method,  and  10  per  cent  by  the  Langenbeck  and  Lane 
methods  combined. 


t'  Peso  ending  paLatiixe    a. 

Txasopa-Latme  cl.  -tl 

posterior  (palatine  oartal 
Internal 
nxaxilLaTij   a. 


Branelxes  i>o 

soj^t  palate 

palatine'  a  ^-'^^  tonsil 

BrarvcVt   ano-stoTUOsinc 


Great 


uritK    asoendind    palatine     a. 


Fig.   246. — Blood  supply    of    the   palate   (New). — Sagittal    section  showing  the  position 
of  the  anterior  and  posterior  palatine  arteries  and  their  anastomosis. 


Necessary  Apparatus 

Mouth  Gag. — Good  exposure  of  the  cleft  with  proper  illumination 
is  essential  if  the  palate  is  to  be  closed  with  any  degree  of  satisfaction  to 
the  operator.  The  exposure  can  be  obtained  by  using  one  of  the  many 
forms  of  mouth  gags.  I  have  found  the  Whitehead  type  with  tongue 
depressor    to    be    as    good    as    any.     Sometimes   in   infants   a   small 


282 


PLASTIC    SUEGERY 


appendix  retractor  in  each  angle  of  the  mouth  will  give  sufficient 
exposure.  Any  well-constructed  electric  head  light,  or  hand  light, 
will  supply  illumination. 

Aspirator. — A  continuous  suction  aspirator  with  a  flexible  metal 
nozzle  is  of  great  value  and  serves  to  keep  the  field  clear  of  blood  and 
mucus.     More  important  still  it  may  prevent  aspiration  pneumonia. 


I  2  3  4  567 

Pig.  247. — Elevators  useful  in  cleft  palate  work. — i  and  2.  The  ordinary  blunt  dis- 
sector, side  and  front  views.  The  instrument  is  15.  cm.  (6  inches)  long  and  the  widest 
portion  of  the  blade  is  0.7  cm.  (about  ^'j  g  inch)  wide.  3.  The  blunt  dissector  with  its 
blade  bent  forward.  4.  This  long  narrow  elevator  20  cm.  (8  inches)  long  has  a  blade  0.5 
cm.  (3^  inch)  wide  at  its  widest  portion.  5  and  6.  Brophy's  angled  elevators.  Note  the 
difference  in  the  angles  of  the  blades  to  the  shaft.  These  instruments  are  13.75  cm.  (5/^ 
inches)  long,  and  the  widest  portion  of  the  blade  is  0.2  cm.  (H2  inch).  All  of  these  instru- 
ments are  blunt  and  are  used  for  separating  the  mucoperiosteal  flap  from  the  hard  palate. 


Knives. — Any  thin  narrow-bladed  knife  will  do  for  making  the  pri- 
mary incisions  and  for  the  denudation  of  the  edges  of  the  flaps.  A  rec- 
tangular knife  is  of  use  in  loosening  flaps,  especially  in  the  narrow  angle 
high  up  and  just  behind  the  intermaxilla. 

Forceps.^ — For  handling  the  tissues  I  use  a  long  curved  pair  of  mouse 
tooth  forceps,  the  teeth  of  which  are  quite  small. 


HARELIP  AND  CLEFT  PALATE  283 

Tissue  Hooks. — Small  single  and  double  hooks  are  most  useful  for 
drawing  the  flaps  together  and  everting  the  edges  during  suturing. 
They  deserve  more  frequent  use,  inasmuch  as  gentle  handling  of  the 
tissues  is  especially  desirable  in  these  cases. 

Elevators. — For  raising  the  mucoperiosteal  flaps  from  the  hard 
palate,  elevators  of  several  shapes  may  be  used.  The  long  narrow 
staphylorrhaphy  elevator,  Brophy's  angular  elevators  and  the  ordinary 
blunt  dissector  are  sufficient  (Fig.  247). 

Needles.- — A  small-sized  full-curved  needle  (Lane's)  is  the  best  for 
the  ordinary  sutures.  In  closing  the  mucoperiosteal  flap  it  is  sometimes 
difficult  to  place  the  sutures  with  a  free  needle;  in  these  cases  I  use  a 
rigid  right-angled  curved  needle  (right  and  left)   (Fig.  248). 


K)^ 


Fig.  248. — I.  Rectangular  knife  for  loosening  edges  which  cannot  be  reached  with  an 
ordinary  scalpel.  2.  Curved  needle  on  a  rigid  handle.  These  are  in  pairs,  right  and  left. 
Instead  of  an  eye  a  slot  is  an  improvement,  the  needle  being  passed  through,  and  the  suture 
caught  in  the  slot  and  pulled  back  with  the  needle. 

Needle  Holder. — Including  one  I  invented  myself  I  have  yet  to  see 
a  satisfactory  needle  holder  for  cleft  palate  work,  and  although  there 
are  a  number  of  these  on  the  market,  I  ordinarily  use  the  Halsted 
hemostatic  forceps  for  holding  the  needles,  and  And  this  as  good  as 
anything  so  far  developed. 

Suture  Material. — I  prefer  very  fine  waxed  silk  for  the  uvula,  horse- 
hair for  the  soft  palate;  horsehair,  silkworm  gut,  or  fine  silver  wire  for 
the  hard  palate. 

TECHXIC 

Preparation  of  the  Field.^ — After  the  patient  has  been  anesthetized, 
the  lips  and  surrounding  tissues  should  be  sponged  with  ether  or 
benzine,  followed  by  alcohol.  Then,  after  the  gag  has  been  inserted, 
the  operative  field  should  be  sponged  with  ether  and  painted  with 
one-third  strength  tincture  of  iodin. 

Operation. — After  carefully  trying  most  of  the  methods  reported.  I 
do  not  feel  able  to  adopt  any  single  technic  for  closing  a  cleft  in  the 
palate,  but  have  collected  what  experience  has  shown  me  to  be  the 


284 


PLASTIC    SURGERY 


good  points  in  several  operations.     The  combination  has  proved  most 
satisfactory. 

In  separating  the  mucoperiosteal  flap  from  the  hard  palate  I  use  the 
method  described  by  Berry  and  Legg.  A  small  incision  is  made  down 
to  the  bone,  either  inside  or  outside  of  the  posterior  palatine  artery, 


3  4 

Fig.  249. — Method  of  closing  an  incomplete  cleft  of  the  hard  palate  associated  with  a 
complete  cleft  of  the  soft  palate. — i.  The  short  dark  line  near  the  alveolar  margin  shows  the 
puncture  wound  through  which  the  mucoperiosteal  flap  is  detached  from  the  hard  palate. 
This  incision  may  be  lengthened  if  necessary.  This  dark  line  below  this  shows  the  situation 
of  the  relaxation  incision  which  may  be  joined  to  the  upper  incision.  After  the  flaps  have 
been  separated  on  each  side  and  the  attachment  of  the  soft  to  the  hard  palate  divided,  then 
the  margins  of  the  mucoperiosteal  flaps  are  trimmed  as  indicated  by  the  dotted  line  and 
the  margins  of  the  soft  palate  split  lengthways.  2.  The  on-end  mattress  sutures  in  place. 
These  sutures  may  be  used  in  both  hard  and  soft  palate  as  shown  in  3,  or  the  same  suture 
can  be  used  to  evert  both  mucous  borders  in  the  soft  palate,  as  shown  in  4.  3.  The  on-end 
mattress  suture  everting  the  mucous  edges  (Blair).  4.  The  on-end  mattress  suture  in 
the  soft  palate  everting  the  mucous  edges  on  the  pharyngeal  and  oval  surface.  A,  the 
mucous  membrane  of  the  pharyngeal  surface.  B,  the  tissues  of  the  soft  palate.  C,  the 
oral  mucous  membrane. 


according  to  the  situation  in  which  subsequent  relaxation  incisions 
should  be  made. 

The  bleeding,  which  is  usually  quite  severe  after  the  initial  incision 
for  the  insertion  of  the  elevator,  is  soon  controlled  by  pressure.  Some- 
times the  posterior  palatine  artery  is  nicked,  and,  when  this  occurs,  it 
is  better  to  divide  the  artery  completely  to  allow  it  to  retract.     In  many 


HARELIP  AND  CLEFT  PALATE 


285 


cases  the  control  of  bleeding  consumes  much  time  and  adds  consider- 
ably to  the  length  of  the  operation. 

A  long  narrow  elevator  should  be  inserted  through  this  small  inci- 
sion and  the  periosteum  and  overlying  mucous  membrane  should  be 
thoroughly  separated  from  the  hard  palate,  the  separation  extending 
from  the  posterior  edge  over  as  large  an  area  as  is  required.     The  ele- 


> 


Y, 


Fig.  250. — Method  of  closing  a  complete  cleft  of  the  hard  and  soft  palates. — i  and  2. 
In  some  instances  it  is  inadvisable  to  attempt  the  closure  of  the  entire  cleft  at  one  opera- 
tion. The  posterior  portion  of  the  hard  and  the  soft  palate  has  been  closed.  A  defect  is 
left  just  behind  the  alveolar  margin.  This  defect  is  usually  best  closed  by  a  small  flap  with 
its  pedicle  at  the  margin  of  the  cleft.  The  dotted  line  shows  the  outline  of  the  flap  A, 
raised  from  the  widest  side.  An  incision  is  made  along  the  margin  of  the  cleft  on  the  oppo- 
site side  and  the  mucoperiosteal  flap  B  is  undermined.  The  flap  A  is  then  turned  over  and 
its  free  edge  is  drawn  well  under  B  by  properly  placed  sutures.  3.  Shows  the  flap  in  place 
and  the  sutures  tied.  Ths  raw  surface  from  which  the  flap  A  was  raised  is  allowed  to 
granulate.  The  junction  of  the  intermaxillary  bone  with  the  superior  maxilla  may  be  made 
at  this  time  by  freshening  and  trying  to  make  a  bony  union,  or  this  may  be  postponed. 
4.  Shows  another  method  of  suturing.  Using  the  ordinary  mattress  sutures  in  the  muco- 
periosteal flap  and  the  on-end  mattress  suture  in  the  soft  pali^le. 

vator  is  then  forced  through  the  margin  of  the  cleft  and  separates  it. 
A  similar  procedure  is  carried  out  on  the  other  side.  Then,  with  a 
pair  of  curved  scissors,  the  soft  palate  is  cut  away  from  its  attachment 
to  the  hard  palate  on  each  side.  This  is  a  most  important  step,  and 
must  be  thoroughly  done  if  the  flaps  are  to  be  brought  together  in  the 
midline  without  tension.  It  is  important  that  the  tissues  at  the 
junction  of  the  hard  and  soft  palate  be  kept  as  thick  as  possible  in  order 


286 


PLASTIC    SURGERY 


to  avoid  subsequent  perforation,  due  to  sloughing  which  often  occurs  at 
this  point. 

The  margins  of  the  mucoperiosteal  flaps  should  then  be  pared,  but 
the  soft  palate  should  be  split  in  the  manner  described  by  Davies-Colley 
and  H.  M.  Sherman,  which  saves  loss  of  tissue  and  gives  a  broader 
surface  for  suture.  The  soft  palate  is  then  closed,  beginning  at  its 
junction  with  the  hard  palate,  and  then  the  uvula.  I  prefer  the  on- 
end  mattress  suture  for  the  soft  palate  throughout  as  used  by  Blair. 
The  hard  palate  is  then  sutured  with  the  same  stitch. 

I  have  often  made  the  mistake  of  inserting  too  many  sutures^  and  have 
found  that  these  cases  almost  invariably  do  badly.  Use  only  enough 
sutures  to  approximate  the  edges  thoroughly,  and  do  not  put  in  an 
unnecessary  stitch.  It  is  always  a  temptation  to  make  the  line  of 
closure  perfect  in  appearance,  but  experience  has  shown  me  that  those 
cases  with  only  the  absolutely  necessary  sutures  do  best. 


Pig.  251. — Method  of  separating  the  soft  palate  from  the  posterior  edge  of  the  hard 
palate  {Berry  and  Legg). — Sagittal  semi-diagrammatic  section  through  the  palate  of  an 
infant,  i.  Temporary  incisor  tooth.  2.  Permanent  incisor.  3.  Mucous  membrane  on 
floor  of  nostril.  4.  Bony  palate.  5.  Aponeurosis  of  soft  palate.  6.  Soft  palate.  7. 
Mucoperiosteum  of  the  hard  palate.  8.  Blades  of  a  pair  of  scissors.  9.  Space  formed  by 
detachment  of  mucoperiosteal  flap.  A.  Parts  before  operation.  B.  Mucoperiosteal 
flap  detached  from  hard  palate.  The  soft  palate  remains  attached.  Blades  of  scissors 
inserted.      C.  After  division  of  the  aponeurosis  and  nasal  mucous  membrane. 

It  is  often  unwise  to  do  a  complete  operation  at  one  time.  Some- 
times it  is  safer  to  close  the  soft  palate  and  the  posterior  portion  of  the 
hard  palate  first,  and  complete  the  repair  of  the  anterior  portion  sub- 
sequently. The  closure  of  the  anterior  portion  of  the  hard  palate  is 
especially  difficult,  as  there  is  little  chance  of  mobilizing  flaps  by  the 
edge-to-edge  principle.  In  this  situation  it  is  best  to  raise  a  flap  after 
the  Lane  method  from  the  wider  side  and  to  insert  it  into  a  pocket  on 
the  narrower  side,  as  has  been  recommended  by  Sherman  and  others. 
Lane's  procedure  is  a  particularly  valuable  method  for  closing  defects 
in  this  region. 

Relaxation  incisions  should  be  avoided  if  possible,  and  in  some 
cases   are   not   necessary.     Nevertheless,   it  is   better   to   make   them 


HARELIP  AND  CLEFT  PALATE 


287 


than  to  have  any  tension  on  the  sutures.  If  the  beginner  shoulcl  make 
the  relaxation  incisions  as  illustrated  in  many  text-books,  his  flaps  would 
slough  from  defective  blood  supply. 

I  have  found  the  best  incision  for  the  majority  of  cases  to  be  that 
described  by  Berry  and  Legg.  It  begins  "  a  little  in  front  of  the  junction 
of  the  hard  and  soft  palates,  near  the  alveolus,  but  internal  to  the 
posterior  palatine  foramen;  it  should  extend  obliquely  backward  to  a 
point  nearly  halfway  between  the  posterior  end  of  the  alveolus,  and  the 
posterior  margin  of  the  soft  palate."  This  incision  should  pierce  the 
soft  palate. 

In  some  severe  cases  this  incision  must  be  prolonged,  and  others  not 
endangering  the  blood  supply  made  in  order  to  give  necessary  relaxation. 


u- 


-15  lyi  M 

30  M  M 


^=^  U==^^^=U 


Fig.  252. — Diagrams  showing  the  difference  in  the  heights  of  the  palatine  arch,  and 
illustrating  the  point  that  the  higher  the  arch  the  more  easily  is  closure  made  {Berry 
and  Legg). — The  clefts  in  A  and  B  are  of  exactly  the  same  width.  In  A^  where  the  arch  is 
low  the  detached  mucoperiosteal  flaps  do  not  meet  in  the  midline.  In  B'  where  the  arch  is 
high,  the  detached  mucoperiosteal  flaps  meet  easily  in  the  midline.  In  A^  with  the  low 
arch,  the  approximation  is  made  possible  by  lateral  liberating  incisions. 

I  have  tried  the  various  methods  of  using  paraffined  tapes,  lead  and 
steel  plates,  and  the  like,  to  reinforce  the  palate  sutures,  but  find 
them  unnecessary  in  the  ordinary  cases  if  tension  on  the  sutured  flaps 
has  been  properly  relieved. 

The  Two-stage  Edge-to-edge  Method.— In  certain  cases  where 
the  cleft  is  especially  wide,  or  where  the  soft  tissues  are  thin,  it  is  advisa- 
ble to  do  the  edge-to-edge  operation  in  two  stages.  The  muco- 
periosteal flaps  are  raised  through  lateral  incisions  without  breaking 
through  the  cleft  margins,  and  then  after  the  soft  palate  has  been 
separated  from  its  attachment  to  the  hard  palate,  the  spaces  between 


288  PLASTIC    SURGERY 

the  bone  and  flap  are  packed  with  iodoform  gauze.  By  this  means 
the  flaps  are  thickened,  the  blood  supply  is  made  more  sure,  and  there 
is  also  stretching  of  the  tissues.  After  four  or  five  days  the  ordinary 
edge-to-edge  closure  is  carried  out.  This  is  a  very  valuable  procedure 
and  by  its  use  a  cleft  can  be  closed  which  would  otherwise  be  hopeless. 

Post -operative  Care. — The  same  precautions  should  be  exercised 
as  have  already  been  mentioned  under  Harelip.  In  addition  to  con- 
tinuous instillation  of  water  by  the  rectum,  a  subcutaneous  infusion 
of  normal  salt  solution  is  advisable  whenever  a  considerable  amount  of 
blood  has  been  lost.  Sterile  water  should  be  given  for  the  first  12 
hours,  and  then  sterile  liquids,  water  being  given  after  each  feeding. 
Very  soft  diet  may  be  allowed  after  one  week,  and  after  two  weeks 
there  may  be  a  gradual  increase,  care  being  taken  for  several  weeks 
to  avoid  lumpy  food.  Every  effort  should  be  made  to  keep  the  mouth 
clean  with  swabs,  sprays  or  irrigations. 

Older  children  may  be  allowed  to  get  up  after  the  shock  of  the 
operation  has  passed.     Talking  should  not  be  allowed  for  at  least  a  week. 

There  is  httle  advantage  gained  by  daily  inspection  of  the  wound, 
as  nothing  can  be  done  at  this  period  even  if  the  stitches  do  not  hold. 
In  older  children  one  is  usually  able  to  remove  the  deep  stitches  without 
an  anesthetic,  but  for  very  young  patients  primary  anesthesia  is  often 
necessary.  I  prefer  to  allow  the  deep  stitches  to  remain  for  two  weeks. 
If  the  edges  have  not  united  by  that  time  there  is  little  hope  of  union. 

Complications  in  Cleft  Palate 

VoMiTiXG  which  is  long  continued  may  be  a  serious  complication, 
but  fortunately  this  is  usually  temporary,  lasting  only  a  few  hours. 
When  it  is  a  symptom  of  acidosis,  it  is  always  a  serious  matter. 

A  temperature  of  100°  to  io3°F.  is  not  uncommon  in  young  children 
within  the  first  24  hours,  and  should  give  little  uneasiness  if  it  subsides 
within  48  hours.  It  may  be  due  to  the  absorption  of  the  swallowed 
blood,  the  bruising  of  the  tissues,  or  to  the  prolonged  operation. 

Occasionally  a  child  will  develop  a  high  temperature  a  few  days 
after  operation,  and  in  these  cases,  after  everything  else  has  been 
eliminated,  one  must  bear  in  mind  middle-ear  infection. 

Bronchitis  and  bronchopneumonia  are  complications  that  are 
not  infrequent  and  are  sometimes  fatal. 

Slough  of  the  Flaps. — At  times  death  of  the  flap  occurs, 
due  either  to  poor  circulation  or  strangulation  of  the  tissues  by  tightly 


HARELIP  AND  CLEFT  PALATE  289 

drawn  sutures.  I  have  seen  flaps  in  which  the  circulation  was  ap- 
parently good,  melt  away  under  an  infection  over  which  we  had  no 
control. 

Hemorrhage. — In  certain  cases  oozing  continues  for  some  time 
after  operation,  and  if  this  keeps  up  it  may  become  serious.  Digital 
pressure  usually  is  sufficient  to  control  it,  but  this  may  cause  a  sloughing 
of  all  the  tissues,  or  separation  of  the  margins.  At  times  it  may  be 
necessary  to  remove  stitches  and  pack  with  gauze.  So  far  I  have  been 
fortunate  enough  not  to  have  had  a  case  of  secondary  hemorrhage, 
(except  in  one  hemophiliac),  but  such  accidents  have  been  reported. 

There  are  two  other  methods  of  treating  cleft  palate,  the  principles 
of  which  are  radically  different  from  that  already  described,  (i) 
Forcible  approximation  of  the  sides  of  the  cleft  within  three  months 
after  birth,  preferably  within  a  few  hours. 

(2)  The  turnover  flap  method. 

I .  Forcible  approximation  of  the  edges  is  accomplished  in  two  ways : 

A.  By  clamps,  which  bite  into  the  outer  side  of  the  upper  gums 
and  which  are  tightened  every  few  days.  These  are  allowed  to  remain 
in  the  mouth  for  several  weeks.  Hammond,  Roberts,  and  Ulrich  have 
designed  clamps  for  this  purpose.  In  my  opinion  they  should  never  be 
employed. 

B.  By  wiring;  Brophy  and  Blair  are  the  principal  exponents  of 
this  method,  and  in  their  hands  the  results  seem  good. 

I  have  never  felt  justified  in  performing  this  operation.  It  is 
certainly  dangerous  because  of  liability  of  extensive  sloughing,  and  the 
results  in  the  cases  I  have  seen  operated  on  by  other  surgeons  have  been 
far  from  satisfactory. 

The  principle  of  the  operation,  in  brief,  is  to  pass  a  silver  wire 
through  both  superior  maxillae  from  a  point  just  back  of  the  malar  proc- 
esses, high  enough  to  be  above  the  palate.  One  or  two  other  wires 
are  also  inserted  at  the  same  level  behind  the  first  one.  The  wires  are 
passed  through  holes  in  lead  plates  molded  to  fit  the  contour  of  the 
bones,  and  these  lie  between  the  cheek  and  the  bone.  After  the  edges 
of  the  cleft  have  been  freshened  throughout,  the  margins  are  pressed 
together  with  the  thumbs  until  they  are  approximated,  and  the  wires 
are  twisted  so  that  the  bones  are  held  together.  The  soft  palate  may 
or  may  not  be  closed  at  this  time.  The  plates  and  wires  are  allowed  to 
remain  in  place  about  four  weeks. 

Much  can  be  done  toward  narrowing  the  cleft  by  an  orthodontic 
apparatus  applied  on  the  inside  of  the  mouth,  consisting  of  a  nut  and 

19 


290 


PLASTIC    SURGERY 


screw  bar,  and  bands  for  the  teeth.  Dr.  G.  V.  I.  Brown  of  Milwaukee, 
has  been  able  to  accomplish  a  good  deal  with  it  in  children  as  young  as 
18  months.  This  apparatus  can  also  be  applied  to  older  children  with 
success. 

2.  The  Turnover  Flap   Method. — The  Davies-Colley  method  was 
the  first  devised,  and  was  recommended  in  those  cases  in  which  the 


^^  ^ 


Fig.  253. — The  flap  method  of  closing  a  cleft  palate  (Davies-Colley). — i.  The  incision 
AB  with  its  center  just  internal  to  the  last  molar  tooth  is  made  down  to  the  bone  in  front 
and  through  the  soft  palate  behind.  Through  this  incision  the  mucoperiosteal  flap  is 
separated  from  the  posterior  half  of  the  hard  palate.  The  incision  CD  from  just  in  front 
of  the  cleft  and  0.625  cm.  (3^  inch)  from  its  margin,  is  carried  backward,  gradually 
approaching  the  junction  of  the  hard  and  soft  palate;  the  tissues  are  loosened  and  turned 
inward.  The  incision  should  be  continued  along  the  cleft  edge  of  the  soft  palate  in  such 
a  way  as  to  split  that  structure  lengthwise.  The  flap  EFG,  which  consists  of  muco- 
periosteum,  is  raised  by  the  incision  EP,  which  runs  parallel  to  and  0.4  cm.  (3^  inch)  from 
the  insertion  of  the  last  molar  tooth  to  the  median  incisor.  The  incision  FG  runs  backward 
0.4  cm.  (3^^  inch)  from  the  margin  of  the  cleft  of  the  hard  palate,  and  is  continuous  with  the 
split  in  the  soft  palate,  as  on  the  other  side.  The  shaded  portion  on  the  hard  palate 
indicates  the  area  in  which  the  periosteum  is  separated,  and  on  the  soft  palate  the  depth  to 
which  the  tissues  are  split.  The  tissue  internal  to  the  line  FG  should  be  loosened  and 
turned  inward.  The  insert  represents  a  transverse  vertical  section  along  the  line  XY. 
2.  The  margins  of  the  flaps  M  and  N,  and  the  upper  plane  of  the  soft  palate  are  sutured 
together.  The  insert  indicates  the  method  of  turning  and  suturing.  3.  The  mucoperi- 
osteal flap  O  is  then  shifted  over  the  sutured  line  and  secured,  and  the  lower  plane  of  the  soft 
palate  is  sutured. 

defect  was  too  wide  for  the  edge-to-edge  closure.     The  diagrams  will 
fully  explain  the  principle  (Fig.  253). 

Lane's  method  is  based  on  the  Davies-Colley  method.  Lane  raises 
a  flap  of  mucoperiosteum  from  one  side,  with  its  base  close  to  the  margin 
of  the  cleft.  Then  on  the  opposite  side  the  mucoperiosteal  flap  is 
undermined  through  an  incision  along  the  margin  of  the  cleft.  The 
free  edge  of  the  flap  from  the  opposite  side  is  then  drawn  into  this  pocket, 
and  is  held  by  sutures  (Figs.  254-260). 


HARELIP  AND  CLEFT  PALATE 


291 


Fig.  254. — Lane's  operation  for  complete  unilateral  cleft  palate  (Binnie). — Reflect  the 
flap  outlined  by  the  dotted  line  7,  5.  6,  8.  Make  the  incision  through  the  mucoperiosteum 
to  the  bone  on  the  hard  palate,  but  only  through  the  subniucosa  in  the  soft  palate.  The 
line  5  to  6  is  made  on  the  outer  surface  of  the  alveolus  near  the  reflection  of  the  mucosa  to 
the  cheek.  When  the  flap  is  raised  the  posterior  palatine  vessels  are  caught  and  clamped. 
On  the  side  of  the  cleft  attached  to  the  septum  pull  the  uvula  and  soft  palate  forward  to 
expose  the  nasal  surface.  Divide  the  posterior  external  edge  of  the  soft  palate  4,  3, 
through  the  submucosa  and  extend  this  incision  along  the  nasal  surface  of  the  hard  and 
soft  palate  to  the  cleft  3,  2.  The  incision  down  to  the  bone  is  continued  along  the  cleft  2,  i, 
and  across  the  alveolus  margin  i,  9. 


Fig.  255.  Fig.  256. 

Lane's  operation,  continued  (Binnie). 
Fig.  255. — Reflect  the  mucous  flap  4,  3,  2,  and  separate  the  mucoperiosteal  flap  from 
the  bone  through  the  incision  2,  1.9.  Then  divide  the  attachment  of  the  soft  to  the 
hard  palate  in  the  usual  way.  Turn  over  the  flap  7,  5,  6,  8.  so  that  its  mucous  surface 
is  toward  the  nose  and  its  raw  surface  toward  the  mouth.  Draw  the  free  edge  of  the  flap 
7,  5.  6,  9.  under  the  flap  9,  i,  2,  3,  4.  and  suture  it  into  position  as  indicated. 
Fig.   256. — Indicates  the  position  of  the  flaps  after  they  are  sutured. 


292 


PLASTIC    SURGERY 


In  this  way  very  large  defects  may  be  covered.  This  method  was 
much  used  for  a  time,  but  is  now  employed  principally  as  an  adjunct  to 
the  edge-to-edge  operation.  The  end  results  were  not  what  were  hoped 
for  and  the  danger  of  slough  was  found  to  be  greater.  If  it  occurs,  the 
patient  is  left  in  bad  condition  for  subsequent  operations.     For  detailed 


Fig.  257.  Fig.  258. 

Lane's  operation  for  wide  double  incomplete  cleft  palate. 
Fig.  257. — yiake  the  flap  i,  2,  3,  as  in  a  case  of  single  complete  cleft  palate.  On  the 
opposite  side  make  the  incision  6  through  the  mucoperiosteum  along  the  edge  of  the  cleft. 
Make  the  incisions  7  and  8  on  the  nasal  side  of  the  soft  palate,  and  reflect  the  flap  of 
mucous  and  submucous  tissue.  Separate  the  mucoperiosteal  flap  from  the  hard 
palate  and  divide  the  attachment  of  the  soft  to  the  hard  palate,  leaving  the  oral  mucosa 
intact. 

Fig.  258. — Then  insert  the  flap  i,  2,  3  and  suture  its  free  edge  well  under  10,  6,  7,  8. 

information  on  this  method  the  reader  is  referred  to  Brophy's,  Blair's, 
and  Lane's  works  on  this  subject. 


Secondary  Operations  for  Cleft  Palate 

Secondary  operations  are  often  required  in  cases  operated  on  for 
cleft  palate,  when  there  has  been  a  complete  or  partial  failure  of  the 
sutured  flaps. 

If  the  failure  is  complete  the  operation  should  be  done  over  again, 
but  the  chance  for  success  is  less  than  at  first.     Berry  and  Legg  advise 


HARELIP  AND  CLEFT  PALATE 


293 


the  secondary  operation,  following  a  complete  failure,  as  soon  as  the 
edges  are  healthy,  or  in  about  three  or  four  weeks.  My  own  preference 
is  to  wait  for  a  longer  period  until  healing  is  complete. 

In  partial  failure  the  chances  of  success  are  much  greater,  but  a 
considerable  period  should  elapse  before  the  secondary  operation.  I 
have  been  astonished  at  the  amount  of  spontaneous  closure  of  defects 
in  the  suture  line  which  at  first  seemed  to  call  for  an  extensive  secondary 


Fig.  259.  Fig.  260. 

Lane's  operation  for  wide  cleft  of  the  soft  palate   (Binnie). 

Fig.  259. — The  dotted  line  i,  5,  6,  7,  8,  indicates  the  outline  of  the  flap  of  mucoperios- 
teum  which  is  raised  and  frees  the  hard  palate  and  mucosa  from  the  soft  palate  and  cheek. 
Prom  the  nasal  surface  of  the  soft  palate  on  the  opposite  side  the  flap  i,  2,  3,  4,  is  raised. 
The  bases  of  these  flaps  are  at  the  edge  of  the  cleft. 

Pig.  260. — The  flap  i,  5,  6,  7,  8,  is  turned  over  with  mucous  surface  inward  toward  the 
nasal  cavity.  The  flap  i,  2,  3,  4,  is  turned  outward  mth  its  mucous  surface  toward  the 
mouth.  They  are  over-lapped  and  sutured  in  position.  Care  must  be  taken  not  to  in- 
jure the  musculature  of  the  soft  palate  in  raising  these  flaps. 


operation.  It  is  useless  to  attempt  to  close  a  defect  of  any  size  in  the 
hard  palate  by  simply  freshening  the  edges  and  suturing.  Extensive 
undermining  and  lateral  relaxation  incisions  are  necessary.  Defects 
in  the  anterior  portion  of  the  hard  palate  are  best  closed  with  pedun- 
culated flaps  shaped  in  the  way  best  suited  for  the  special  case. 

Holes  in  the  hard  palate  due  to  syphiHs,  tuberculosis,  typhoid 
ulceration,  or  injury,  are  treated  in  a  similar  manner. 

Hett  found  the  inferior  turbinates  of  great  use  in  repairing  wounds 


294 


PLASTIC    SUEGERY 


causing  hard  palate  perforations.  These  bones  may  also  be  employed 
in  closing  certain  resistant  palate  perforations  in  which  there  is  much 
scar,  and  only  a  small  amount  of  tissue  available.  The  bone  is  partially 
severed  from  its  attachment,  is  pushed  down  and  used,  after  freshening 
the  edges,  as  a  sort  of  pedunculated  flap  to  plug  the  opening,  the  pedicle 


Pig.  261. — Operation  for  closing  a  partial  cleft  of  the  hard  and  soft  palates  (Schoe- 
maker). — i.  The  dotted  lines  indicate  the  incisions.  The  margins  of  the  cleft  are  either 
denuded  or  split.      2.   The  flap  is  shifted  toward  the  midline  and  sutured. 

being  severed  later  (Fig.  262).  Defects  in  the  soft  palate  can  usually 
be  closed  by  freshening  the  edges  and  suturing,  although  if  much  scar 
tissue  is  present,  lateral  relaxation  incisions  are  necessary.  Sometimes 
lateral  pedunculated  flaps  may  be  shifted  in  to  good  advantage. 

It  is  necessary  in  some  cases  to  operate 
six  or  eight  times  before  the  defects  are 
completely  closed. 

Transplantation  of  Extrapalatal  Tissues 
to  Close  Palate  Defects. — There  are  certain 
cases  which  have  lost  (through  sloughing 
following  previous  operative  procedures) 
practically  all  of  the  soft  tissue  usually  em- 
ployed for  closure  of  the  cleft.  These  de- 
fects can  be  closed  by  using  tissues  obtained 
from  the  buccal  mucous  membrane,  as  de- 
scribed by  Blair,  and  also  by  means  of 
pedunculated  flaps  of  tissue  from  inside  the 
lip  and  cheek,  or  from  the  skin  of  the  neck 
(Fig.  263). 

The  flap  from  the  neck  is  inserted  through  an  opening  made  between 
the  cheek  and  jaw  bone,  in  much  the  same  manner  as  in  lining  a  cheek 
defect.  It  might  be  advantageous  to  use  Thiersch  grafts  on  the  raw 
surface  of  the  flap  to  prevent  subsequent  contracture,  and  then  after 
the  graft  has  taken,  to  suture  the  flap  with  the  epithelium  on  both 
sides  into  the  palate  defect.     It  is,  of  course,  necessary  that  all  scar 


Fig.  262. — Method  of  using 
the  anterior  and  posterior  ends 
of  the  inferior  turbinates  to  fill 
up  traumatic  perforations  in  the 
floor  of  the  nose  {Hell). 


HARELIP  AND  CLEFT  PALATE 


295 


tissue  be  removed  from  the  edges  of  the  defect,  before  suturing  in  the 
flap  with  silkworm  gut  or  horsehair.  The  jaws  should  be  held  apart, 
in  the  pedunculated  flap  operations  (to  prevent  interference  with  the 
blood  supply)  with  a  block  wired  to  the  teeth  until  the  pedicle  is  cut. 
The  pedicle  should  be  divided  in  from  ten  to  fourteen  days,  after  which 
the  rest  of  the  opening  is  closed,  the  base  of  the  flap  being  turned  out 
again  and  utilized  for  filling  the  upper  portion  of  the  neck  defect. 

After  proper  closure  of  the  lip  and  palate,  by  whatever  method,  the 
child  should  be  placed  in  the  hands  of  a  competent  dental  surgeon  who 
should  take  charge  of  straightening  the  teeth  and  adjusting  the  line 
of  the  jaws  by  proper  orthodontic  measures. 

Obturators. — The  great  majority  of  cleft  palate  cases  should  be 
treated  by  operation.  Up  to  a  short  time  ago  I  would  have  said  all 
cases,  but  recently  I  have  seen  a  "bleeder"  with  very  scant  tissue  in 


Fig.  263. — The  repair  of  a  palate  defect  by  means  of  mucosa  from  the  cheek  (Blair). — 
I.  The  dotted  lines  indicate  the  incisions  made  to  raise  the  flap  of  mucoperiosteum  from 
the  hard  palate  and  mucosa  and  buccinator  muscle  from  the  cheek.  2.  The  flap  A  is 
shifted  inside  the  alveolar  margin  on  each  side.  It  may  be  necessary  to  fracture  the 
hamular  process  on  each  side  and  extensive  undercutting  may  be  required.  I  have  not 
been  very  favorably  impressed  with  this  method. 

which  there  was  no  possible  chance  of  operative  success,  and  in  this  case 
I  advised  the  use  of  an  obturator. 

In  some  old  cases  which  have  been  the  rounds  it  is  useless  to  try 
further  operative  work.  Then  an  obturator  offers  the  best  solution  to 
the  problem. 

In  my  opinion  obturators  should  be  used  only  in  those  cases  in  which 
operative  procedures  have  been  exhausted,  or  in  those  which  from  their 
nature  preclude  operative  interference. 

Fairly  good  speech  is  possible  following  the  use  of  obturators  cover- 
ing defects  in  the  hard  palate,  if  the  soft  palate  is  reasonably  pliable. 
Obturators  to  which  artificial  vela  are  attached  are  seldom  satisfactory 
from  the  speech  standpoint,  although  Mitchell  reports  successful  cases. 


296  PLASTIC    SURGERY 

It  is  impracticable  to  use  obturators  on  growing  children,  but  later 
they  may  be  very  useful  in  some  cases. 

Training  in  Articulation.- — Special  attention  should  be  given  to 
speech  training,  and  if  this  is  carefully  done,  by  the  parents  or  by  profes- 
sional teachers,  good  results  will  be  obtained.  The  child  should  be 
taught  to  speak  slowly,  to  pronounce  every  syllable,  and  to  give  full 
value  to  every  consonant  sound.  Details  of  the  method  may  be 
found  in  works  on  Oral  Surgery. 

BIBLIOGRAPHY 

Abbe,  R.     "Med.  Rec."     X.  Y.,  April  2,  1898. 

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Berry  &Legg.     "Harelip  and  Cleft  Palate,"  1912. 

Blair,  V.  P.     "Internat.  Clin."     Philadelphia,  1916,  xxvi,  s.  iv,  211. 

"Surgery  and  Diseases  of  the  Mouth  and  Jaws,"  3d  Ed.,  1917. 
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"Lancet."     London,  March  6,  1915,  479. 
Brophy,  T.  W.     "Oral  Surgery,"  191 2. 
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"The   Surgery  of   Oral   Diseases   and   Malformations,"  2d  Ed.,  191 7   (Extensive 
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Cargile.     "Southern  Med.  Jour.,"  Oct.,  1909. 

Davies-Colley,  J.  N.     "Trans.  Royal  Medico-Chir.  Soc,"  1894,  Ixxvii,  237. 

"Trans.  Med.  Soc,"  xlx,  1896,  70. 
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"Jour.  Amer.  Med.  Assn.,"  Sept.  11,  1915,  915. 

Federspiel,  M.  X.     "Internat.  Jour.  Orthodontia,"  ii.  No.  8. 

"Surg.,  Gyne.  &  Obst.,"  Nov.,  1918,  532. 
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GoYDER,  F.  \V.     "Brit.  Jour.  Surg.,"  Oct.,  1913,  259. 

Helding,  C.     "Ergebnisse  der  Chir.  &  Orthopadie,"  1913,  85. 
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Kredel,  L.     "Zent.  f.  Chir.,"  July  29,  1911,  1025. 

Ladd,  W.  E.     "Boston  Med.  &  Surg.  Jour.,"  Jan.  14,  1915. 
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Malgaigne,  J.-F.     "Manuel  de  Medecine  Operatoire."     Paris,  1861,  462. 

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Mayo,  C.  H.     Quoted  by  Binnie.     "Operative  Surgery,"  7th  Ed.,  134. 

Mitchell,  V.  E.     "Amer.  Jour.  Surg.,"  March,  1Q17,  57. 

MoRESTiN,  H.     "Bull,  de  I'Academie  de  Med."     Paris,  April  16,  1918,  303. 

N^LATON,  A.     "Elements  de  Pathologic  Chirurgicale."     Paris,  1876,  iv,  497. 
New,  G.  B.     "Minnesota  Medicine."     St.  Paul,  Jan.,  1918,  8. 
NicoLL,  J.     "Edinburgh  Med.  Jour.,"  Nov.,  1913,  .xi.  No.  5. 
NovoTXY,  J.     "Wien.  klin.  Wchnschr.,"  June  3,  1909,  779. 

Ombredanne,  L.     "Jour,  de  chir.  de  Paris,"  Jan.,  191 2,  viii,  i. 
Owen,  E.     "Trans.  JMed.  Soc,"  xlx,  1896,  68. 

"Cleft  Palate  and  Harelip,"  1904  (Medical  ISIonograph  Series). 

"Surgery  of  the  Mouth,  Teeth  and  Jaws."     In  Keen's  Surgery,  1908,  iii,  614. 

Parrish,  I.     "Amer.  Jour.  JNIed.  Science,"  1838,  xxii,  97. 

Reich,  A.     "Zent.  f.  Chir.,"  June  24,  191 1,  S59. 

RiEGNER.     "Beitrage  z.  klin.  Chir.,"  May,  1914. 

Roberts,  J.  B.     "Trans.  Phila.  Academy  of  Surgery."     "Anns.  Surg.,"  Jan.  1918,  no. 

Roux,  Ph.-J.     "Memoire  sur  la  Staphyloraphie."     Paris,   1826. 

RowL.\NDS  &  Turner.     "Jacobson's  Operations  of  Surgery,"  i,  505,  6th  Ed. 

ScHOEMAKER.     "  Ccntralbl.  f.  Chir.,"  Nr.  39,  1914,  1514. 
Sherman,  H.  M.     "Jour.  Amer.  Med.  Assn.,"  Dec.  8,  1917,  1966. 
Stark,  W.  T.     "Jour.  ISIissouri  State  Med.  Assn.,"  1917,  xiv,  415. 

Thompson,  J.  E.     "  Surg.,  Gyne.  &  Obst.,"  May,  191 2,  498. 
Turck,  R.  C.     "  Surg.,  Gyne.  &  Obst.,"  Oct.,  1913,  500. 
TuRNURE,  P.  R.     Johnson's  "Operative  Therapeusis,"  1915,  i,  457. 

Ulrich,  I.     "Zent.  f.  Chir.,"  Oct.  18,  1913,  1634. 

Vander  Veer,  A.     "Handbook  of  Med.  Science,"  iv,  1914,  902. 


CHAPTER  XII 
EXSTROPHY  OF  THE  BLADDER  (ECTOPIA  VESICAE) 

This  distressing  condition  is  caused  by  the  maldevelopment  of 
the  structures  which  make  up  the  anterior  wall  of  the  bladder,  and  the 
corresponding  portion  of  the  abdominal  wall.  The  posterior  wall 
of  the  bladder  protrudes  much  like  a  rosette,  and  on  the  lower  portion 
of  this  mucous  surface  the  urine  is  constantly  being  discharged  from  the 
exposed  ureteral  orifices.  Associated  with  this  condition  ununited 
pubic  bones  and  epispadias  are  found.  Occasionally  double  inguinal 
hernia  is  present. 


Fig.  264. — Complete  exstrophy  of  the  bladder  with  epispadias. — This  patient  was 
subsequently  cured  by  transplanting  the  ureters  with  a  rosette  of  mucous  membrane  into 
the  rectum. 


Exstrophy  of  the  bladder  is  rare,  occurring  only  once  in  from 
30,000  to  50,000  births.     It  occurs  much  more  frequently  in  males. 

Berger  says  that  of  74  patients  not  operated  upon,  born  with 
exstrophy  of  the  bladder,  only  2},  passed  their  20th  year,  68  per  cent 
dying  of  pyelonephritis. 

Time  of  Operation. — Children  should  be  at  least  four  or  five 
years  of  age.  Good  physical  condition  is  essential  for  such  a  serious 
operation. 

Three  general  groups  of  operative  procedures  have  been  devised 
for  the  correction  of  this  deformity. 

298 


EXSTROPHY  OF  THE  BLADDER 


299 


(A)  Those  Whose  Object  is  the  Plastic  Reconstruction  of  a 
Bladder. — (i)  By  the  formation  of  the  anterior  wall  from  pedunculated 
flaps  of  adjacent  skin.  (Roux,  1852,  Nelaton,  Thiersch,  Wood,  and 
others.)  Wood's  method  of  forming  the  skin  flaps  from  the  abdominal 
wall  is  that  most  commonly  used,  and  the  diagram  is  self-explanatory 
(Fig.  265). 


Fig.  265. — Wood's  operation  for  exstrophy  of  the  bladder  (Binnie). — i.  The  flap 
A  is  made  of  the  abdominal  skin  with  its  pedicle  about  .625  cm.  (I4  inch)  from  the  edge 
of  the  bladder.  Its  size  should  be  planned  to  allow  for  shrinkage.  If  it  is  desired  to  cover 
the  dorsum  of  the  penis  with  the  same  flap  AD  should  be  raised.  Flaps  B  and  C  are  ob- 
tained from  the  skin  of  the  abdominal  wall  external  to  the  bladder  and  flap  A,  and  are  raised 
for  covering  flap  A  after  it  is  turned  down  and  sutured.  2.  The  flap  A  has  been  turned 
down,  epitheHal  surface  inward,  and  sutured  to  the  freshened  edges  of  the  bladder.  Flap  C 
is  raised  and  shifted  inward  as  is  flap  B,  and  their  free  ends  are  sutured  together  to  cover 
flap  A.  The  raw  surface  is  made  smaller  by  drawing  in  the  surrounding  skin  and  the  rest 
is  skin  grafted.  If  the  extension  D  of  flap  A  is  used,  it  is  sutured  to  the  freshened  edges  of 
the  penile  gutter.  There  are  many  modifications  of  this  method  which  must  be  made  to 
suit  the  individvial  case. 

(2)  By  the  use  of  an  isolated  loop  of  intestine.  (Rutkowsky,  1899, 
and  othefs.) 

(3)  By  freshening  and  uniting  the  edges  of  the  defective  bladder, 
after  bringing  together  the  widely  separated  pubic  bones.  To  accom- 
plish this,  Trendelenburg  divides  the  sacroiliac  synchondrosis  on  each  side . 
Konig,  Koch,  and  others  secure  the  same  result  by  division  or  fracture 
of  the  horizontal  and  descending  rami  of  the  pubes,  followed  by  suture 
of  the  loosened  margins  of  the  bladder.  Passavant  uses  an  orthopedic 
pressure  apparatus  to  bring  the  bones  together. 


300 


PLASTIC    SURGERY 


(4)  Schlange  mobilizes  the  lower  end  of  each  rectus  muscle,  chisels 
away  the  bony  insertions,  and  slides  them  toward  the  midline,  where 
they  are  secured.     The  edges  of  the  bladder  are  then  united. 

(5)  The  bladder  is  formed  by  isolating  a  loop  of  intestine.  The 
continuity  of  the  bowel  is  reestablished  and  the  lower  end  of  the  loop 
is  brought  down  between  the  rectum  and  the  anal  sphincter.  The 
ureters  are  implanted  in  the  upper  end  of  the  loop.     (Gersuny,  1898.) 


^^mERS 


LATERAL  SKIN  INCISION 
FOR  PLASTIC  CLOSURE 


3  4 

Pig.  266. — Segond's  operation  for  exstrophy  of  the  bladder  (Kanavef). — i.  Shows 
the  condition  before  operation.  The  dotted  line  indicates  the  incision  around  the  bladder 
and  on  the  penis.  2.  The  bladder  turned  down  over  the  penis.  The  dotted  lines  indicate 
the  incisions  for  the  removal  of  the  excess  bladder  wall.  3.  The  bladder  wall  sutured  to 
the  epispadiac  mucous  membrane.     4.   Skin  closed  over  penile  and  abdominal  defects. 

(6)  The  bladder  is  formed  from  the  isolated  lower  end  of  the  cecum, 
the  appendix  being  brought  through  the  abdominal  wall  as  in  an  appen- 
dicostomy,  and  the  urine  being  removed  through  a  catheter.  (Mak- 
kas,  1910.) 

(B)  Those  Whose  Object  is  the  Diversion  of  the  Urinary 
Stream:  to  the  Urethra,  Vagina,  or  Skin  Surface. — (i)  The 
implantation  of  the  ureters  into  the  urethral  groove,  and  closing  of  the 
gutter.     (Sonnenberg,  1885,  Segond,  and  others.)     (Fig.  266.) 


EXSTROPHY  OF  THE  BLADDER  3OI 

(2)  Implantation  of  the  ureters  into  the  vagina.  (Pawlic,  1891, 
Chavasse,  and  others.) 

(3)  Transplantation  of  the  ureters  into  the  skin  surface  of  the  loin. 
(Harrison,  1896,  Bottomley,  and  others.) 

(C)  Those  Whose  Object  is  the  Diversion  of  the  Urinary 
Stream  into  the  Rectum. — (i)  The  implantation  (intraperitoneally) 
of  the  trigone  of  the  bladder,  with  the  ureteral  orifices  intact,  into  the 
wall  of  the  sigmoid  rectum.  (Maydl,  1892,  Lendon,  Peters,  Moynihan, 
C.  H.  Mayo,  W.  D.  Haggard,  and  many  others.) 

These  operations  are  also  done  extraperitoneally.  Instead  of  the 
trigone  only,  the  whole  bladder  has  been  implanted. 

(2)  The  ureters  with  a  rosette  of  bladder  attached  have  been  im- 
planted into  separate  incisions  in  the  rectum  by  the  extraperitoneal 
route.     (Bergenhem,  1894,  Peters  and  others.) 

(3)  Implantation  of  the  ureters  alone  into  the  intestine.  (Simon, 
1846.  Lloyd,  Fowler,  Smith,  C.  H.  Mayo,  and  others.) 

The  above  is  a  brief  outline  of  some  of  the  many  operative  pro- 
cedures which  have  been  practised  for  this  deformity. 

To  my  mind  only  three  methods  promise  results  which  will  be  accept- 
able to  the  patient,  and  I  shall  describe  in  brief  the  technic  which  seems 
to  me  most  desirable  in  each  of  these  methods.  On  these,  as  a  basis, 
the  operator  can  introduce  the  modifications  called  for  by  the  peculiari- 
ties of  individual  cases. 

The  Transplantation  of  the  Ureters  into  the  Skin  of  the  Loin. 
Bottomley's  Operation.  First  Step. — A  10.  cm.  (4-inch)  incision  is 
made  following  in  a  general  w^ay  the  crest  of  the  ilium,  about  2.5  cm. 
(i  inch)  above  and  to  its  inner  side.  The  external  oblique  aponeurosis 
and  muscle  is  split  in  the  direction  of  its  fibers;  the  deeper  muscular 
layers  are  divided  sufficiently  to  allow  the  peritoneum  to  be  pushed  for- 
ward; the  ureter  is  located  and  freed  by  blunt  dissection  for  several 
inches  of  its  length,  and  is  divided  where  it  crosses  the  iliac  vessels.  The 
distal  end  is  ligatured,  and  through  a  small  incision  in  the  loin  the  proxi- 
mal end  is  brought  to  the  surface  and  sutured  to  the  skin  with  chromic 
catgut  stitches,  which  do  not  penetrate  the  mucosa.  The  end  of  the 
ureter,  which  should  project  about  0.312  cm.  (^s  inch),  is  split  and  the 
flaps  are  turned  outward  and  sutured.  The  abdominal  wound  is  closed 
in  layers.     Both  sides  are  done  in  this  way. 

Second  Step. — Two  weeks  later  the  vesical  mucous  membrane 
and  distal  portions  of  the  ureters  are  removed,  and  the  defect  is  closed 
with  a  skin  and  fat  flap,  shifted  in  from  the  abdominal  wall.     Following 


302 


PLASTIC    SURGERY 


this  operation  the  patient  must,  of  course,  wear  some  apparatus  held 
in  place  with  a  belt,  for  collecting  the  urine. 

The  operation  is  simple  and  comparatively  safe.  There  is  probably 
less  danger  of  renal  infection  than  in  the  other  methods  to  be  described. 
The  disadvantage  is  the  necessity  of  wearing  a  collecting  apparatus, 
but  this  can  be  easily  fitted  over  the  fistulse  in  the  back,  and  with  proper 
care  the  urinary  odors  can  be  avoided. 

Transplantation  of  the  Bladder  into  the  Rectum  (Extraperi- 
toneally).  Moynihan-Maydl  Operation.^ — A  catheter  is  passed  for  lo. 
cm.  (4  inches)  into  each  ureter,  and  is  fixed  there  with  a  single  stitch. 
An  incision  is  made  at  the  junction  of  the  mucosa  and  the  skin  all 


Incision  around  the 
bladder 


Suture  fixing  catheters  in 
ureter 


Ureteral  catheters 


Peritoneum 


_^     Uretheral  groove  in  penis 


Pig.  267.- 


-Moynihan's  operation  for  exstrophy  of  the  bladder     {J acohson) .- 
is  liberated  without  opening  the  peritoneum. 


-The  bladder 


around  the  bladder,  which  is  gradually  raised  by  careful  dissection  until 
it  is  isolated,  leaving  only  as  its  pedicle,  so  to  speak,  the  two  ureters.  As 
much  tissue  is  left  around  each  ureter  as  possible,  so  as  to  avoid  the 
possibility  of  damage  either  to  the  ureter  itself,  or  to  its  vessels. 

As  soon  as  the  bladder  is  well  isolated  it  is  drawn  upward  out  of  the 
way  by  an  assistant.  In  the  bottom  of  the  wound  the  rectum  with  its 
peritoneal  reflection  is  now  seen.  The  peritoneum  is  then  stripped 
upward  from  the  front  of  the  rectum  until  10.  or  12.5cm.  (4  or  5  inches) 
of  the  bowel  are  exposed.  The  finger  of  an  assistant  having  been  passed 
into  the  rectum  to  make  it  prominent,  traction  sutures  are  placed  and 


EXSTROPHY  OF  THE  BLADDER 


303 


an  incision  8.75  cm.  (3I2  inches)  in  length  is  made  along  the  anterior 
surface  of  the  bowel.  Into  this  opening  the  bladder  is  placed,  being 
turned  upside  down  so  that  its  former  anterior  surface  becomes  posterior, 
and  its  former  lower  end  becomes  the  upper.  The  ureters  instead  of 
passing  forward  to  the  bladder  pass  backward,  and  the  catheters  pass 
into  the  rectum  and  out  at  the  anus,  the  sphincter  having  previously 


Deep  surface  of  the  bladder 


The  incision  into  the  rectum 


Fig.  268. — Moynihan's  operation  for  exstrophy  of  the  bladder,  continued  (Jacobson). 
The   ureters   should  not  be  stripped  as  freely  as  shown,   as  the  blood  supply  must  be 
preserved. 

been  dilated.  The  edge  of  the  bladder  and  the  cut  edges  of  the  rectum 
are  sutured  together  with  a  continuous  suture  on  each  side  for  the 
mucous  membrane,  and  any  appropriate  infolding  intestinal  suture 
for  the  outside.  A  few  additional  sutures  may  be  inserted  when  neces- 
sary. In  the  Maydl  operation  the  trigone  is  implanted  into  the  rectum 
intraperitoneally  (Figs.  267-269). 

The  Bergenhem-Peters  operation  is  done  extraperitoneally,  and  the 
procedure  is  practically  identical  with  the  Moynihan  operation  just 


304 


PLASTIC    SURGERY 


described,  except  that  each  ureter  with  a  rosette  of  bladder  tissue  sur- 
rounding the  orifice  is  separately  implanted  on  opposite  sides  of  the 
rectum.  Both  ureters  may  be  implanted  at  the  same  operation,  or  one 
at  a  time. 

The  Implantation  of  the  Free  Ureters  into  the  Sigmoid.  C.  H. 
Mayo's  Operation. — According  to  Mayo  the  secret  of  successfully 
anastomosing  the  ureter  into  the  bowel  is  to  tubularize  the  ureteral 
entrance  for  3.125  cm.  {i}>4,  inches).  His  operation  is  based  on  Coffey's 
modification    of  Witzel's   gastrostomy  operation   and  is   carried  out 


Lower  part  of  the  bladder 

Rectal  wall 

Upper  part  of  the  bladder 


Ureteral  catheters  brought  out 
through  the  anus. 


Fig.  269. — Moynihan's  operation  for  exstrophy  of  the  bladder,  continued  (Jacobson). — 
The  bladder  has  been  rotated  so  that  its  upper  end  can  be  sutured  to  the  lower  part  of 
the  incision  in  the  rectum.     The  ureteral  catheters  are  brought  out  through  the  anus. 

as  follows:  A  low  lateral  pelvic  incision  is  made,  preferably  on  the 
right  side  first,  and  the  sigmoid  is  exposed.  It  naturally  passes  to  the 
left  and  can  always  be  found  on  this  side,  whereas  if  the  incision  is  made 
on  the  left  side  first,  the  slack  bowel  may  be  difficult  to  find.  The 
peritoneum  and  muscularis,  in  a  longitudinal  band,  are  incised  longi- 
tudinally for  about  3.125  to  3.75  cm.  {i}i  to  i}^-^  inches)  down  to  the 
mucous  membrane,  but  not  through  it.  The  ureter  is  exposed  by  an 
incision  in  the  peritoneum  in  the  posterior  pelvic  wall,  and  is  isolated 
to  within  2.5  or  3.75  cm.  (i  or  i>^  inches)  of  the  bladder,  where  it  is 


i 


EXSTROPHY  OF  THE  BLADDER 


305 


divided  and  the  distal  end  ligated.  From  6.25  to  7.5  cm.  (2}^  to  3 
inches)  of  the  ureter  are  exposed,  the  posterior  peritoneal  incision  is 
closed  by  suture  to  the  point  where  it  emerges.  The  lower  end  of  the 
ureter  is  spHt  for  0.625  cm.  {}i  inch),  a  curved  needle  with  chromic 
catgut  is  passed  through  the  end,  the  catgut  is  tied,  and  the  short  end 
of  the  thread  is  cut.  A  small  perforation  is  made  into  the  lumen  of  the 
bowel  in  the  lower  end  of  the  incision  through  the  mucous  membrane, 
to  prevent  contamination  of  the  wound.  A  large  curved  rubber-cov- 
ered clamp  is  used  to  hold  the  bowel  in  position,  and  the  union  is  made 
within  the  curve  of  the  clamp.     The  curved  needle  carrying  the  catgut 


eoL  "bo    en,cL  oj^ 
xoTe"tev 


Fig.  270. — C.  H.  Mayo's  operation  for  exstrophy  of  the  bladder. — The  ureter  has  been 
freed  and  longitudinal  incision  made  in  the  wall  of  the  sigmoid  down  to  the  mucosa.  In 
the  lower  portion  a  small  button-hole  has  been  made  and  through  this  the  catgut  suture 
attached  to  the  ureter  has  been  passed  coming  through  the  bowel  below. 

attached  to  the  end  of  the  ureter  is  passed  into  the  lumen  of  the  bowel 
through  the  small  opening,  and  out  through  the  wall  of  the  bowel 
1.25  cm.  (Jo  inch)  below  it.  The  drawing  of  the  chromic  catgut 
suture  pulls  the  end  of  the  ureter  into  the  lumen  of  the  bowel.  The 
needle  is  then  passed  once  through  the  peritoneum  and  muscularis,  in 
order  that  the  catgut  may  be  tied  to  hold  the  ureter  fixed  within  the  wall 
of  the  intestine.  The  sides  of  the  incision  in  the  outer  wall  of  the  bowel 
are  closed  over  the  ureter,  the  needle  including  its  outer  tissue  in  two 

or  three  sutures.     A  second  row  of  peritoneal  sutures  is  placed  over  this, 

20 


3o6 


PLASTIC    SURGERY 


extending  down  over  the  tied  knot  of  the  fixation  suture  which  holds  the 
ureter  in  place.  This  gives  the  ureter  a  natural  duct  entrance.  The 
slightest  pressure  from  within  closes  the  duct,  but  not  sufficiently  to 
prevent  delivery  of  urine  by  the  automatic  and  intermittent  waves 
of  contraction  occurring  about  six  or  eight  times  a  minute  during  the 
period  of  activity  (Fig.  270  and  271). 

The  intestine  is  held  by  a  few  sutures  to  the  posterior  peritoneum, 
so  as  to  cover  the  ureteral  entrance.     It  is  best  to  do  but  one  side  at  the 


\cchta,cl- 


'llfetex- 


Fig.  271. — C.  H.  Mayo's  operation  for  exstrophy  of  the  bladder,  continued.     The  ureter  has 
been  drawn  down  into  the  bowel  and  the  bowel  wall  is  being  infolded  over  the  ureter. 

first  operation,  as  the  urine  is  absorbed  from  the  large  bowel  like  a 
Murphy  drip.  Tolerance  is  soon  acquired,  however,  and  the  slight 
uremic  mental  apathy  disappears  in  a  week.  The  second  ureter  may  be 
transplanted  with  no  trouble  in  from  one  to  two  weeks  after  the  first 
operation.  A  small  tube  may  be  kept  in  the  rectum  for  the  first  few 
days  unless  it  adds  to  the  discomfort.  Usually  at  once,  or  at  least 
within  a  few  days,  the  urine  will  be  passed  at  moderately  frequent 
intervals. 

Comments 

In  those  operations  whose  object  is  to  reconstruct  a  bladder,  what- 
ever the  method  used,  the  result,  even  if  successful,  is  merely  the  for- 


EXSTROPHY  OF  THE  BLADDER  307 

mation  of  a  reservoir  which,  being  without  a  sphincter,  has  not  the 
power  to  retain  the  urine.  These  receptacles  soon  become  infected 
and  very  foul,  and  infection  may  extend  from  them  up  the  ureters. 

Fistulae  occur  where  skin  flaps  are  used,  and  urinary  concretions 
form  in  the  newly  made  bladder,  whether  it  be  lined  with  skin  or  with 
bowel  mucous  membrane.  The  only  advantages  of  the  method  are 
that  the  bladder  mucosa  is  protected,  and  therefore  the  condition  is  not 
so  painful;  and  that  a  collecting  apparatus  can  be  attached  more 
easily  than  before  such  an  operation. 

The  plastic  problems  in  these  cases  are  fascinating,  but  the  results 
do  not  justify  the  time  taken  and  the  multiple  operations  necessary. 

The  implantation  of  the  ureters  into  the  sigmoid-rectum,  either 
with  a  portion  of  the  bladder,  or  free,  if  properly  done  are  quite  worth 
while,  and  many  good  results  have  been  obtained,  especially  since 
intestinal  operative  technic  has  been  perfected.  The  immediate  danger 
of  uremia  due  to  absorption  of  urine  from  the  bowel  and  the  later 
danger  of  ascending  infection  must  be  borne  in  mind;  but  when  we 
take  into  consideration  that  the  same  danger  (but  possibly  to  a  less 
degree)  also  confronts  the  non-operated  case,  and  compare  this  with 
the  comfort  and  satisfaction  of  the  patient,  who  can  lead  for  the  first 
time  a  comparatively  normal  life,  the  risk  is  well  worth  taking.  In  time 
these  patients  can  hold  the  urine  as  long  as  four  or  five  hours. 

A  number  of  good  results  have  been  reported  after  implantation 
of  the  ureters  into  the  back  (by  the  Harrison-Bottomley  method), 
and  this  is  probably  the  operation  of  choice  for  patients  over  40  years 
of  age  (Mayo). 

Buchanan,  in  1909,  collected  98  cases  of  patients  who  had  survived 
the  intestinal  implantation  of  intact  ureters  with  a  part  of  the  bladder 
wall  (Maydl  and  Bergenhem  methods)  and  has  tabulated  the  results 
as  follows:  eleven  died  of  ascending  renal  infection  (11.2  per  cent); 
two  died  of  preexisting  renal  disease;  seven  died  of  causes  other  than 
renal  disease;  two  died  of  causes  unknown;  one  was  reported  with 
polyuria;  eleven  were  not  heard  from  after  leaving  the  hospital;  sixty- 
four  were  well  at  the  last  report;  of  these  thirteen  reported  well  within 
one  year  after  operation;  twenty-six  were  reported  as  well  between 
one  and  three  years  after  operation;  ten  were  reported  as  well  between 
three  and  six  years  after  operation;  fifteen  were  reported  as  well  between 
six  and  twelve  years  after  operation. 

Immediate  Mortality,  Maydl  Method. — (Direct  intraperitoneal 
implantation  of  the  trigone,  including  both  ureteral  orifices,  in  the 


3o8  PLASTIC    SURGERY 

wall  of  the  rectum)  28.7  per  cent.  Of  fifty-seven  recoveries  by  this 
method  65  per  cent  lived  one  year  and  24  per  cent  over  five  years. 

Immediate  Mortality,  Bergenhem  Method. — (Independent  ex- 
traperitoneal implantation  of  the  ureters,  each  with  a  rosette  of  bladder 
wall  into  the  rectum)  11. 5  per  cent. 

Stevens,  in  1916,  added  sixteen  cases  to  Buchanan's  Maydl  group, 
and  found  the  total  immediate  mortality  28.1  per  cent.  Of  the  sixty- 
nine  recoveries  from  operation  67.7  per  cent  lived  over  one  year,  and 
26.1  per  cent  over  five  years. 

To  Buchanan's  Bergenhem  group,  he  added  seven  cases,  and  found 
the  total  immediate  mortality  15  per  cent.  Of  twenty-eight  recoveries 
from  operation  60.7  per  cent  lived  over  one  year,  and  21.4  per  cent 
over  five  years. 

It  is  striking  that  the  immediate  mortality  following  the  Maydl 
operation  (28.1  per  cent)  is  greater  than  that  following  the  Bergenhem 
operation  (15  per  cent).  This  is  probably  due  to  the  intraperitoneal 
route  usually  employed  in  performing  the  Maydl  operation,  and  the 
elimination  of  this  risk  (intraperitoneal  route)  in  the  Bergenhem  opera- 
tion.    After  recovery  the  ultimate  results  are  about  the  same. 

The  Bergenhem  method  is  simpler,  and  one  ureter  can  be  implanted 
at  a  time,  thus  avoiding  possible  uremia. 

In  C.  H.  Mayo's  most  recent  paper  he  gives  the  results  of  operative 
treatment  in  21  cases:  six  were  done  by  the  plastic  method;  none  of 
these  patients  were  able  to  control  the  urine;  one  died  six  months 
later  of  traumatic  exstrophy  at  childbirth;  three  were  submitted  to  an 
implantation  of  the  ureters  and  a  portion  of  the  bladder  (Maydl- 
Moynihan  method);  two  died  in  the  hospital  of  uremia;  thirteen 
were  submitted  to  a  transplantation  of  free  ureters  into  the  bowel; 
of  these  one  died  in  the  hospital,  one  died  from  pneumonia  several 
weeks  after  discharge,  and  two  others  died  three  years  later  from  other 
causes. 

BIBLIOGRAPHY 

Bergenhem.     "Jahresbericht  f.  Chir.,"  1895,  979. 
Berger,  p.     "Semaine  Med."     Paris,  1883,  iii,  5. 

"France  Med."     Paris,  1889,  ii,  894. 
BiNNiE,  J.  F.     "Operative  Surgery,"  7th  Ed.,  672. 
BooGHER,  J.     "Urol.  &  Cutan.  Rev.,"  1916,  xx,  376. 
BOTTOMLEY,  J.  T.     "Jour.  Amcr.  Med.  Assn.,"  July  13,  1907,  141. 
Buchanan,  J.  J.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  1909,  146.     (Extensive  bibliography.) 

Cabot.     "Modern  Urology,"  1918,  ii,  37. 

Chavasse.     "Lancet."     London,  1899,  i,  161. 

CoFPEY.     "Jour.  Amer.  Med.  Assn.,"  Feb.  11,  191 1,  397. 


1 


EXSTROPHY  OF  THE  BLADDER  309 

DuPLAY,  S.     "Ashhurst's  Internat.  Encycl.  Surg.,"  1886,  vi,  499. 

Fowler.     "Amer.  Jour.  Med.  Science,"  1898,  c.w,  270. 

Gersuxy,  R.     "Wien.  klin.  Wchnschr.,"  1898,  Xr.  43,  990. 

Hagg.^rd,  W.  D.     "Southern  Med.  Jour.,"  Nov.,  191 7,  862. 
Harrisox,  R.     "Ashhurst's  Internat.  Encycl.  Surg.,"  1886,  vi,  335. 
"Lancet."    London,  1897,  1091. 

Kanavel,  a.  B.     "Surgical  Clinics."     Chicago,  i,  191 7,  153. 

Koch,  C.  F.  A.     "Centralbl.  f.  Chir.,"  1897,  .x.xiv,  953. 

KoNiG,  F.     "Verhandl.  der  Deut.  Gesellsch.  f.  Chir.,"  1896,  Bd.  r,  77. 

Lendon.     "Brit.  Med.  Jour.,"  1906,  i,  961. 
Lloyd.     "Lancet."     London,  1851,  ii,  370. 

^La.kkas.     "Zent.  f.  Chir.,"  Aug.  13,  1910,  1064. 
^L\YDL.     "Wiener  med.  Wchnschr.,"  1894,  Nr.  25,  1113. 

"Wiener  med.  Wchnschr.,  1896,  Nr.  28,  1241. 
]\L\YO,  C.  H.     "Anns.  Surg.,"  Julj^  1913,  133.     (Extensive  bibliography.) 

"Jour.  Amer.  Med.  Assn.,"  Dec.  22,  1917,  2079. 
Moyxihax,  B.  G.  a.     "Anns.  Surg.,"  Feb.,  1906,  237. 

N^LATOX,  A.     "Gaz.  hebd.  de  Med.  et  Chir.,"  1854,  Bd.  i. 
Xeudorfer,  J.     "Fortschr.  d.  Med."     Berlin,  1886,  iv,  255. 

Orlow.     "Revue  de  Gynec.  et  de  Chir.  Abdom."     Paris,  1903,  vii,  796. 

Passavant,  J.     "Arch.  f.  klin.  Chir.,"  1887,  xxxiv. 
Pawlik.     "Wien.  klin.  Wchnschr.,"  1891,  Bd.  xvi,  1814. 
Peters,  G.     "The  Canadian  Lancet,"  1899,  xxxii,  23. 
"Brit.  Med.  Jour.,"  June  22,  1901,  1538. 

RoTKOWSKY.     "Centralbl.  f.  Chir.,"  1899,  xxvi,  473. 
Rofx,  J.     "Union  Med.,"  1853,  vii,  Nos.  114-115. 

Schlange.     Cited  by  Binnie:  "Operative  Surgery,"  7th  Ed.,  674. 
Segond,  p.     "Bull,  et  mem.  Soc.  de  chir.  de  Par.,"  1890,  n.  s.  xvi,  435. 
Sherman,  H.  M.     "Jour.  Amer.  Med.  Assn.,"  1905,  xlv,  890. 
Simon.     "Lancet."     London,  1852,  ii,  56S. 
Smith,  Thos.     "St.  Bartholomew's  Reports,"  1879,  xv,  229. 
SONNENBURG.     "Verh.  d.  Deut.  Gesellsch.  f.  Chir.,"  1885,  12. 
Stevens,  A.  R.     "Surg.,  Gyne.  &  Obst.,"  Dec,  1916,  702. 

Thiersch.     "Centralbl.  f.  Chir.,"  1876,  504. 
Trendelenburg.     "Centralbl.  f.  Chir.,"  1885,  857. 
"Anns.  Surg.,"  Aug.,  1906,  281. 

Werelius,  A.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  1911,  158. 

White  &  Martin.     "Genito-urinary  Surgery  and  Venereal  Diseases,"  loth  Ed.,  1917,  469. 
Wood,  John.     "Med.  Times  &  Gaz."     London,  1865,  i,  115. 
"Brit.  Med.  Jour.,"  Feb.,  1880. 


CHAPTER  XIII 
EPISPADIAS 

Epispadias  is  a  rare  congenital  deformity  in  which  a  portion  or  all 
of  the  roof  of  the  urethra  is  absent,  the  canal  being  represented  by  a 
furrow  occupying  the  mid-dorsal  aspect  of  the  penis.  The  penis  is 
usually  short  and  broad,  and  is  curved  upward.  According  to  Baron 
epispadias  occurs  only  twice  to  each  three  hundred  cases  of  hypospadias. 

Time  of  Operation. — The  correction  of  this  condition  by  operation 
should  not  be  undertaken  on  children  under  six  years  of  age. 

TREATMENT 

In  preparing  the  skin  for  operations  for  epispadias  and  hypos- 
padias, I  prefer  thorough  scrubbing  with  soap  and  water  with  gauze, 


Pig.  272. 


-Thiersch's   operation  for  epispadias      (Binnie).- 
glandular  urethra. 


-Method  of  constructing  the 


not  a  brush — followed  by  ether.  lodin  is  too  irritating  to  the  skin  of 
this  region,  and  tends  to  cause  trouble  after  operation. 

In  all  of  these  operations  the  hemorrhage  must  be  thoroughly  checked. 
For  dressings  in  both  epispadias  and  hypospadias  I  use  iodoform  gauze 
wrapped  snugly  around  the  part.  Should  the  tissues  become  ede- 
matous, the  iodoform  gauze  may  be  saturated  with  glycerin. 

Preliminary  Steps. — (i)  The  formation  of  a  perineal  fistula  through 
which  the  bladder  is  drained  during  the  operative  procedure  on  the  urethra. 

{2)  The  Straightening  of  the  Penis. — This  is  accomplished  by 
dividing  the  corpora  cavernosa  close  to  the  pubes,  after  which  the  penis 
is  held  down  with  a  splint  for  several  weeks.  If  the  division  of  the 
corpora  is  not  sufficient,  more  extensive  dissection  and  excision  of  the 
contracted  tissues  must  be  carried  out. 


i 


310 


EPISPADIAS 


311 


The  classical  operation  of  Thiersch  for  the  relief  of  complete  epispa- 
dias is  as  follows: 

(i)  The  Construction  of  a  Urethra  in  the  Glans  Penis. — Two  deep 

incisions  are  made  parallel  to  the  urethral  groove  (Fig.  2^2,  A  and  B). 
A  glass  rod  is  laid  along  the  groove  and  the  spongy  tissue  is  pressed 
down.     The  lateral  flaps  are  then  sutured  over  the  rod. 

(2)  Construction  of  the  Penile  Urethra. — After  healing  is  complete 
in  the  glans,  two  quadrilateral  flaps  are  raised  along  the  whole  length 
of  the  urethral  groove,  the  flap  A  (Fig.  273)  having  its  base  next  to  the 


Fig.  273.  Fig.  274. 

Fig.  273. — Thiersch's  operation  for  epispadias,  continued  {Binnie). — -i  and  2.  Method 
of  constructing  the  penile  urethra. 

Fig.  274. — Thiersch's  operation  for  epispadias,  continued. —  i  and  2.  Method  of  con- 
necting the  newly  formed  channel. 

groove,  and  the  flap  B  having  its  base  away  from  the  groove.  The 
flap  A  is  turned  over  (skin  surface  down) ,  and  is  sutured  under  flap  B 
near  its  base.  Flap  B  is  then  shifted  over  flap  A  and  its  edge  is  sutured 
to  the  raw  edge  left  on  the  skin  of  the  penis  when  flap  A  was  raised. 

(3)  The  Opening  Between  the  Penile  and  Glandular  Portions  of  the 
Urethra  is  Then  Closed  by  Utilizing  the  Redimdant  Prepuce. — A  trans- 
verse incision  CC  is  made  through  the  prepuce  near  its  base  (Fig.  274,  i) 
and  the  glans  is  pushed  through  this  opening,  and  the  defect  is  closed 
by  suturing  the  freshened  edges  of  the  penile  and  glandular  urethra  to 
the  prepuce. 

(4)  The  Epispadial  Opening  Is  Closed  with  a  Pedunculated  Flap 
from  the  Pubis. — The  new  canal  is  united  to  the  epispadial  opening  by 


312 


'     PLASTIC     SURGERY 


id) 

Fig.  275. — Cantwell's  operation  for  epispadias  (Binnie). — -A.  The  dotted  line  indi- 
cates the  incisions  made  at  the  mucocutaneous  junction  of  the  groove.  The  incisions 
penetrate  down  to  the  corpora  cavernosa.  B.  Separate  the  urethra  as  a  pedunculated 
flap  with  its  base  above  from  its  bed  and  hold  it  aside.  C.  Separate  the  corpora  until  the 
skin  on  the  lower  surface  of  the  penis  is  reached.  Then  place  the  urethral  flap  against  the 
skin  in  the  bottom  of  the  channel  between  the  corpora  and  suture  its  edges  over  a  rubber 
tube.  D.  Bring  the  corpora  cavernosa  together  over  the  urethra,  and  close  the  wound. 
Before  beginning  the  operation  bladder  drainage  should  be  established  through  the  peri- 


FiG.  276. — Operation  for  epispadias  (Young). — i.  The  penis  is  held  in  position  by 
two  sutures  placed  in  the  glans  (G).  As  indicated  by  the  black  line  in  the  diagrammatic 
cross  section,  the  incision  on  the  left  side  goes  only  through  the  skin  and  down  to  the  corpus, 
while  on  the  right  the  dissection  is  carried  down  between  the  corpora  until  the  skin  of  the 
under  surface  of  the  penis  is  reached.  2.  The  separation  of  the  corpora  has  been  completed. 
The  skin  edge  is  being  retraced  to  the  right  and  the  edge  of  the  new  urethra  to  the  left, 
exposing  the  right  corpus  (C)  and  exposing  also  the  space  between  the  corpora,  the  floor 
of  which  is  formed  by  the  inner  surface  of  the  skin  of  the  under  surface  of  the  penis.  The 
relations  are  clearly  indicated  in  the  cross  section. 


EPISPADIAS 


313 


means  of  a  pedunculated  flap  of  skin  from  the  pubis,  with  its  epithelial 
surface  next  to  the  urethra  (Fig.  274,  2)  A.  The  raw  surface  may  be 
covered  with  another  flap  A',  or  the  surfaces  may  be  grafted  with 
Ollier-Thiersch  grafts. 

The  objection  to  this  method  of  closure  is  the  presence  of  hair, 
which  always  give  trouble.  This  can  be  overcome  by  thorough  dep- 
ilation  with  radium  or  a;-ray  before  the  flap  is  used,  or  by  the  use  of 
a  flap,  the  under  surface  of  which  should  be  grafted  successfully  before 


Fig.  277. — Young's  operation  for  epispadias,  continued. — i.  The  new  urethra  is  being 
formed  by  a  continuous  suture,  bringing  the  edges  together  over  a  catheter  and  converting 
the  original  groove  into  a  tube.  The  attachment  of  the  urethral  tube  to  the  left  corpus  may- 
be distinctly  seen  both  in  surface  view  and  cross  section.  2.  The  right  corpus  has  been 
rotated,  carrying  the  urethra  down  to  its  new  position  below  and  between  the  corpora. 
The  latter  are  sutured  with  interrupted  sutures  of  chromic  catgut.  The  unfinished  suture 
line  above  permits  a  view  of  the  underlying  newly  formed  urethra. 

being  used  to  fill  the  defect.  This  method  is  much  less  satisfactory 
than  the  following: 

Cantwell's  Operation. — (i)  A  longitudinal  incision  is  made  on  each 
side  of  the  urethral  groove  along  the  line  of  the  mucocutaneous  junction 
from  the  symphysis  to  the  extremity  of  the  glans.  The  incisions  are 
joined  above  the  opening  into  the  bladder  and  should  be  made  down  to 
the  cavernous  bodies  without  injuring  them.  The  urethral  gutter  is 
then  raised  as  a  flap  with  its  pedicle  at  the  base  of  the  penis,  and  is 
held  aside. 

(2)  The    corpora    cavernosa    are   separated   from    each   other    by 


314 


PLASTIC    SURGERY 


sharp  and  blunt  dissection,  until  the  skin  on  the  inner  surface  of  the 
penis  is  reached.  The  urethral  flap  is  laid  in  the  gutter  thus 
formed,  and  is  held  in  position  by  one  or  two  sutures  through  the  skin. 
A  glass  rod,  or  rubber  tube,  is  laid  along  the  urethral  flap,  the  edges  are 
sutured  over  it  to  form  a  canal,  and  the  rod  is  removed.  Above  the 
urethral  canal,  the  corpora  cavernosa  are  brought  together  and  held 

in  position  with  sutures ;  the  skin  is  then 
closed.  The  objection  to  this  method  is 
the  possibility  of  slough  of  the  urethral 
flap,  due  to  poor  blood  supply  (Fig.  275). 
Young's  Operation. — Hugh  H.  Young 
has  recently  published  an  operation  which 
is  an  improvement  on  the  Cantwell 
method,  inasmuch  as  the  blood  supply  of 
the  urethral  flap  is  assured.  The  plates 
describe  the  steps  so  well  that  detailed  ex- 
planation is  unnecessary  (Figs.  276-278). 
Successful  results  have  been  reported 
following  Cantwell's,  Young's,  and  other 
methods. 

After  becoming  familiar  with  Cant- 
well's method  some  years  ago,  I  had  con- 
sidered it  the  method  of  choice,  but  in 
future  I  shall  adopt  Young's  method,  as 
its  advantage  over  the  original  Cantwell 
is  obvious. 

Epispadias  in  the  Female. — This  is  a 
condition  even  more  rare  than  epispadias 
in  the  male. 

For  epispadias  in  the  female,  Stiles  and  others,  advise  the  trans- 
plantation of  the  ureters  into  the  intestine  as  the  only  rational  pro- 
cedure. In  other  words  they  think  that  it  should  be  treated  by  the 
methods  already  described  in  the  chapter  on  Exstrophy  of  the  Bladder. 


Fig.  278. — Young's  operation 
for  epispadias,  continued. — The 
operation  completed.  The  two 
outer  edges  of  the  original  incision 
are  easily  brought  together  in  the 
midline,  making  a  penis  and  glans 
almost  normal  in  appearance. 


BIBLIOGRAPHY 


Baro.v.     Quoted  by  Cabot:  "Modern  Urology,"  1918,  i,  214. 

BiNXiE,  J.  F.     "Operative  Surgery,"  7th  Ed.,  723. 

BcLLiTT,  J.  B.     "Jour.  Amer.  Med.  Assn.,"  1903,  xli,  297. 

Caxtw-ell,  F.  V.     "Anns.  Surg.,"  1895,  xxii,  689. 

DuPLAY,  S.     "Ashhurst's  Internat.  Encycl.  Surg.,"  1886,  vi,  496. 


J 


EPISPADIAS  315 

Maydi,.     "Wien.  mcd.  Wchnschr.,"  1894,  x.w,  pp.  1113;  1169;  1209;  1256;  1297. 

Rowlands  &  Turxer.     "Jacobson's  Operations  of  Surgery,"  6th  Ed.,  ii,  735. 

Stiles,  H.  J.     "Surg.,  Gyne.  &  Obst.,"  August,  1911,  127. 

Thiersch.     "Verhandl.  d.  Deutsch.  Gesellsch.  f.  Chir."     Berlin,  1875,  iv,  16. 

White  and  Martin.     "Genito-urinary  Surgery'  and  Venereal  Diseases,"  loth  Ed.,  191 7 

Young,  H.  H.     ''Jour.  Urol.,"  June,  1918,  237. 


CHAPTER  XIV 
HYPOSPADIAS 

Hypospadias  is  a  congenital  deficiency  of  the  floor  of  the  urethra.^ 
There  are  three  varieties:  (i)  Balanic,  or  Glandular. — The  urethral 
meatus  is  usually  at  the  base  of  the  glans.     The  meatus  is  small.     The 
glans  is  broad,  often  grooved,  and  sometimes  curved  slightly  down- 
ward.    The  frenum  is  absent;  the  prepuce  is  thickened  and  malformed. 

(2)  Penile. — The  urethral  opening  may  be  at  any  place  between 
the  glans  and  the  scrotum.  The  penis  is  often  poorly  developed,  sharply 
curved  downward  and  held  in  this  position  by  a  band  of  dense  fibrous 
tissue.     The  scrotum  is  not  cleft, 

(3)  The  Perineo-scrotal. — The  urethral  opening  may  be  at  any 
point  between  the  peno-scrotal  junction  and  the  perineum.  The 
scrotum  is  cleft.  The  penis  is  poorly  developed,  curved  downward  and 
backward,  and  lies  in  the  scrotal  cleft.  The  testicles  may  or  may  not 
be  fully  developed  and  are  often  undescended. 

Hypospadias  is  quite  a  common  deformity.  Gianturco  has  recently 
found  it  in  0.5  per  cent  of  the  men  in  the  Italian  army.  Fortunately, 
the  majority  of  cases  are  of  the  glandular  or  penile  types. 

The  indications  for  operation  are  inability  to  urinate  normally  and 
the  impossibility  of  straight  erection. 

Quite  frequently  in  the  glandular  form,  and  in  those  cases  of  the 
penile  type  in  which  the  opening  is  fairly  close  to  the  gland,  micturition 
and  the  procreative  function  are  not  materially  interfered  with.  In 
these  cases  an  operation  is  of  doubtful  utility,  except  for  reducing  the 
size  of  the  prepuce,  which  is  always  redundant. 

Time  of  Operation. — I  seldom  operate  under  six  years  of  age, 
and  prefer  to  wait  considerably  longer.  A  number  of  my  cases  have 
been  in  adults  and  they  do  very  well.  In  these  older  patients  post- 
operative erection  must  be  controlled  by  full  doses  of  bromide  by  mouth 
or  rectum,  very  light  diet,  and  the  ice-bags.  Allowance  for  this  erection 
should  also  be  made  in  planning  the  flaps,  and  there  should  be  no  ten- 

^  My  special  interest  in  this  malformation  is  due  to  the  fact  that  a  number  of  them  have 
been  referred  to  me  through  the  courtesy  of  Dr.  Hugh  H.  Young  and  Dr.  J.  T.  Geraghty 
of  the  Brady  Urological  Institute  of  the  Johns  Hopkins  Hospital. 

316 


HYPOSPADIAS 


317 


sion  on  the  sutures.  The  after  care  is  all  important.  Many  operations 
which  would  otherwise  be  successful  are  spoiled  by  inefficient  post-opera- 
tive care. 

TREATMENT 

The  success  of  every  method  for  correcting  these  defects  depends 
on  the  thorough  preliminary  straightening  of  the  penis.  This  should  be 
done  before  anything  else  is  attempted.  If  the  skin  is  tight,  a  transverse 
incision  is  made  and  the  fibrous  bands  holding  down  the  penis  are 
divided  or  excised.     These  bands  are  composed  of  the  poorly  developed 


Fig.  279. — Operation  for  straightening  the  penis  {Diiplay). — i.  The  penis  has  been 
straightened  after  a  transverse  incision  through  the  skin,  and  contracted  fibrous  bands. 
Note  the  longitudinal  defect.  2.  The  transverse  defect  sutured  longitudinally,  with  on- 
end  mattress  sutures.      The  glandular  portion  of  the  urethra  is  shown  completed. 

corpus  spongiosum,  the  thickened  envelope  of  the  penis  and  of  the  con- 
tracted septum  between  the  corpora  cavernosa.  The  skin  defect  is 
closed  longitudinally  or  with  a  pedunculated  flap,  or  is  grafted  (Figs. 
279  and  28c). 

In  any  operation  in  which  the  formation  of  the  urethra,  penile  or 
perineal,  is  attempted,  an  external  urethrotomy,  or  in  selected  cases 
a  suprapubic  cystostomy  should  be  done,  and  a  permanent  catheter 
inserted. 

Of  the  numerous  operative  procedures  advocated  for  the  relief  of 
hypospadias,  I  shall  describe  a  few  of  the  best.  Every  surgeon  will  have 
to  adopt  suitable  modifications  or  combinations  of  the  methods  in 
order  to  lit  the  particular  case. 


3i8 


PLASTIC    SURGERY 


Fig.  280. — Operation  for  straightening  the  penis  (C.  Beck). —  i.  The  dotted  area 
on  the  under  surface  of  the  penis  is  the  raw  surface  formed  by  straightening  the  penis  after 
a  transverse  incision.  The  dotted  areas  on  the  dorsum  of  the  penis  indicate  the  incisions 
made  to  form  the  flap  from  the  prepuce.  2.  The  double  pedicled  flap  of  prepuce  A  is 
brought  forward  over  the  glans  and  is  sutured  into  the  defect  on  the  anterior  surface. 


12  34 

Fig.  281. — C.  Beck's  operation  for  a  mild  hypospadias  {White  and  Marthi). — i.  The 
urethral  opening  at  the  base  of  the  glans.  The  dark  lines  indicate  the  incisions.  2.  The 
urethra  separated.  Note  the  cuff  of  skin  left  around  its  free  end.  3  and  4.  The  urethra 
drawn  through  the  slit  in  the  glans  and  sutured.  In  these  drawings  the  urethra  is  stripped 
so  thoroughly  that  in  actual  practice  it  would  probably  slough. 


HYPOSPADIAS 


319 


Several  methods  of  forming  the  urethra  by  means  of  free  trans- 
plants have  been  introduced.  Nove-Josserand  tunneled  subcuta- 
neously  under  the  skin  from  just  in  front  of  the  urethral  opening  to  the 
end  of  the  glans.  Then  after  cutting  an  Ollier-Thiersch  graft  he 
wrapped  it  around  a  glass  rod  with  the  raw  side  out  and  secured  it  at 
each  end  with  a  ligature.  The  rod  with  the  graft  around  it  was  passed 
through  the  tunnel  and  after  eight  days  the  rod  was  removed. 
Later  this  tube  and  the  urethra  were  connected. 

Segments  of  the  saphenous  vein  were  used  in  a  similar  manner  by 
Tanton  and  others.     A  section  of  ureter  from  a  fresh  dead  bodv  was 


Abnormal 

reLbral 
ipen'ing 


incision 


Fig.  282. — Operation  for  hypospadias  (Bevan). — An  oblong  flap  of  skin  is  dissected 
up  from  around  the  abnormal  opening,  the  portion  of  the  flap  toward  the  scrotum  being 
longer  than  that  toward  the  glans. 

used  by  Schmieden;  the  appendix  was  used  in  a  similar  way  by  Streissler. 

Cantas  used  a  pedunculated  flap  of  skin  from  the  right  thigh  con- 
taining a  section  of  a  vein. 

When  the  defect  is  to  be  repaired  with  a  free  transplant,  a  piece  of 
tissue  much  longer  than  the  defect  must  be  used  to  allow  for  shrinkage. 

These  methods  might  be  worth  while  in  some  cases,  but  for  ultimate 
results  they  cannot  be  compared  with  the  operations  to  be  described 
below. 


;20 


PLASTIC    SURGERY 


Operations  for  the  Glandular  and  the  Less  Pronounced  Penile 
Types.  Beck's  Operation. — Dissect  out  from  its  bed  the  distal  end  of 
the  urethra  with  a  cuff  of  skin,  to  enlarge  it,  and  bring  it  forward  through 
a  tunnel  made  in  the  glans.  (The  urethra  should  not  be  stripped  too 
thoroughly;  otherwise  its  blood  supply  might  be  interfered  with.) 
Suture  the  borders  of  the  cuff  to  the  wound  in  the  glans  and  close  the 
skin  over  the  urethra.     Unless  the  urethra  is  long  enough,  erectility 


Lhru    glansXS."  ^ 


Fig.  283. — Operation  for  hypospadias,  continued  (Bevan). — A  channel  of  considerable 
size  has  been  made  through  the  glans.  Two  mosquito  clamps  are  passed  through  this 
opening  and  grasp  the  loosened  flap  at  each  extremity.  The  flap  is  then  drawn  through  the 
channel. 


will  be  checked.     For  this  reason  this  operation  is  adapted  only  to  very 
mild  cases  (Fig.  281). 

Bevan's  Operation. — Dissect  up  an  oblong  flap  (the  lower  part 
being  longer  than  the  upper)  from  around  the  urethral  opening.  Make 
a  free  opening  through  the  center  of  the  glans  so  that  the  flap  will  not 
be  constricted  when  it  is  brought  through  the  opening.  Pass  two 
mosquito  forceps  through  the  opening  in  the  glans  and  grasp  the  flap 
at  its  upper  and  lower  extremities  and  gradually  draw  it  up  through 
the  opening  as  shown  in  the  diagram.  Suture  the  edges  of  the  flap  to 
the  margins  of  the  wound  in  the  glans  and  close  the  skin. 


HYPOSPADIAS 


321 


This  seems  a  very  rational  procedure  and  Bevan  says  it  can  be  used 
in  cases  where  the  opening  is  as  far  as  3.75  cm.  W^i  inches)  below  the 
normal  meatus.  This  operation  prevents  shortening  of  the  urethra 
— the  disadvantage  of  Beck's  method — and  also  eliminates  the  possibility 
of  a  urethral  slough  (Figs.  282-285). 

Operations  for  More  Extensive  Defects  in  the  Penile  Urethra. 
Duplay's  Operation. — The  glandular  urethra  is  formed  in  the  same 
manner  as  already  described  in  Thiersch's  operation  for  epispadias. 
An  incision  is  made  on  eachside,  about  i.  cm.  (^f;,  inch)  from  the  urethral 


Flap  Sutured  to 
g]a.ns  forming 
X  meaLas 


Correspcindinf 
points    of 
iuLufes   on 
5kin  flap 


m 


Pig.  284. — Operation  for  hypospadias  continued  (Bevan). — i.  The  sutures  are  being 
placed.  2.  The  edges  of  flap  sutured  to  the  margins  of  the  channel  in  the  glans.  3.  The 
flap  lettered  to  show  the  corresponding  points  of  suture. 


groove  and  extending  from  the  glans  to  just  beyond  the  urethral 
opening.  At  each  end  of  these  incisions  a  transverse  cut  is  made  begin- 
ning at  the  urethral  groove  and  extending  beyond  the  longitudinal 
incisions.  (This  incision  can  be  lengthened  subsequently  if  necessary.) 
By  these  incisions  two  flaps  are  outlined  on  each  side  of  the  urethral 
groove,  one  having  its  base  at  the  urethral  groove,  while  the  other  is  in 
the  skin  of  the  body  of  the  penis.     These  flaps  are  raised  and  those  with 

their  bases  at  the  urethral  groove  are  turned  over  a  rod  or  rubber  tube, 

21 


322 


PLASTIC    SURGERY 


SO  that  the  skin  surface  is  next  to  the  rod.  I  prefer  to  make  these  edges 
meet  and  to  suture  them  separately  over  the  tube  with  fine  catgut.  In 
this  way  the  urethra  is  completely  lined  with  epithelium.  The  outside 
flaps  are  then  brought  in  and  closed  with  horsehair  sutures.  I  have 
not  found  it  necessary  to  use  the  lead  plates  advised  by  some  authors 
for  securing  these  sutures.  After  healing  is  complete  and  all  induration 
has  disappeared,  the  extremities  of  this  newly  formed  urethra  are 
joined  above  and  below  to  the  other  channels  (Fig.  286). 

Bucknall's  Operation.     First  Stage. — The  penis  is  drawn  up  on 
the  abdomen  and  the  scrotum  is  drawn  down  between  the  thighs,  so  that 


Fig.  285.- 


-Operation  for  hypospadias,   continued    (Bevan). — The  skin  of  the  penis  drawn 
in  and  sutured  over  the  defect  left  by  raising  the  flap. 


the  tissues  are  on  a  stretch  in  the  midline.  Then  a  longitudinal  inci- 
sion is  made  on  each  side  of  and  0.312  cm.  (>^  inch)  from  the  midline, 
extending  from  the  glans  to  the  abnormal  urethral  orifice.  The  inci- 
sions are  now  lengthened  on  each  side  of  the  scrotal  raphe  until  those 
below  the  urethral  orifice  on  the  scrotum  are  exactly  the  same  length  as 
those  on  the  penis.  This  outlined  area  of  skin  0.625  cm.  (3>^  inch)  wide 
(with  the  urethral  orifice  in  the  center)  is  allowed  to  remain  undisturbed. 
From  the  extremities  of  the  longitudinal  incisions  already  made,  other 


HYPOSPADIAS 


323 


incisions  0.625  cm.  di  inch)  long  are  made  at  right  angles,  and  the  flaps 
thus  marked  out  are  raised  on  each  side  and  rolled  back.  In  this  way 
are  formed  two  long  denuded  strips  1.25  cm.  (^2  inch)  wide  on  each 
side  of  the  undisturbed  skin  in  the  midline.  The  flaps  are  held  in  the 
everted  position  and  the  penis  is  flexed  down  on  the  scrotum  in  the  mid- 
line. Thus  the  median  strip  of  skin  and  the  raw  surfaces  will  be  brought 
into  apposition.  The  strip  of  skin  on  the  penis  will  form  the  roof  and 
the  scrotal  strip  the  floor  of  the  new  urethra.     The  flaps  formed  on  each 


^^y^ 

'  ■W'l'' 

^-     2 

■i 

•\'i 

■■  y 

i.     A 

..  f 

'   1 

1 1 

r    fe 

.  y 

S        Vi 

■\ 

\        Ya 

■  -W 

iiKI 

I  oMTf 


Fig.  286. — Methods  of  covering  the  penile  urethra  (formed  by  Duplay's  method)  with 
skin.  (Modified  after  White  and  Martin). — i.  Incisions  for  Duplay's  operation.  A  and 
B  lateral  flaps.  C  and  D  central  flaps.  2.  Closure  of  the  lateral  flaps  with  on-end  mat- 
tress sutures  after  the  central  flaps  have  been  turned  inward  and  the  edges  sutured.  3.  The 
central  flaps  sutured.  The  lateral  flaps  being  too  short  to  close  over  the  new  urethra. 
A  flap  with  its  base  above  is  outlined  on  the  scrotum.  4.  The  scrotal  flap  is  raised  and 
sutured  over  the  new  urethra.      The  scrotal  defect  is  shown  partially  closed. 


side  of  the  opposed  penile  and  scrotal  flaps  are  sutured  as  shown  in 
the  diagram,  the  stitches  being  about  0.625  cm.  (\i  inch)  apart.  All  the 
sutures  are  placed  before  any  are  tied,  small  rubber  tubes  extending  the 
length  of  the  opposed  flaps  are  inserted  on  both  front  and  back,  and  the 
sutures  are  tied  over  them.  Through  the  channel  thus  formed  Bucknall 
then  passes  a  small  rubber  catheter  into  the  bladder  through  the  newly 
formed  urethra  to  drain  oft'  the  urine.     (It  is  better  to  do  an  external 


;24 


PLASTIC    SURGERY 


urethrotomy   and   insert   a   permanent   catheter.)     The   stitches   are 
removed  after  fourteen  days  (Figs.  288  and  289). 

Second  Stage.— Usually  undertaken  after  three  or  four  weeks,  if 
conditions  are  favorable.  The  penis  and  newly  formed  urethra  are 
dissected  from  the  scrotum  leaving  lateral  flaps  of  scrotal  tissue  on  each 
side  sufliciently  long  to  cover  the  raw  surface  of  the  penis  when  they 


Fig.  287. — Operation  for  penile  hypospadias  (Rochet). — i.  Through  a  short  trans- 
verse incision,  just  above  the  abnormal  urethral  opening,  a  tunnel  is  burrowed  beneath  the 
skin  and  through  the  glans.  2.  A  pedunculated  flap  of  sufficient  length,  with  its  base 
at  the  urethral  opening,  is  raised  from  the  midline  of  the  scrotum,  and  is  sutured,  skin 
surface  inward  around  a  rubber  catheter,  a  portion  of  which  is  inserted  in  the  urethra. 
3.  The  catheter  with  the  flap  attached  is  then  drawn  through  the  tunnel  previously  made, 
and  the  end  of  the  flap  is  sutured  to  the  new  meatus.  The  catheter  may  either  be  left  for 
24  hours,  to  support  the  newly  formed  urethra,  or  may  be  removed  at  once.  It  is  safer  to 
drain  the  bladder  through  an  external  urethrotomy  wound  with  a  permanent  catheter, 
than  to  have  the  urine  flow  along  the  new  channel,  until  healing  is  complete. 


are  brought  together.     The  flaps  and  the  scrotal  defects  are  closed 
vriih  sutures  in  the  midline. 

Bucknall  reports  good  results  in  three  cases.  The  disadvantages 
are  that  the  method  cannot  be  utilized  if  the  scrotum  is  cleft;  hair  may 
develop  on  the  skin  from  the  scrotal  raphe  forming  the  floor  of  the 
new  urethra. 


HYPOSPADIAS 


325 


Van  Hook,  and  later  C.  H.  Mayo,  devised  operations  in  which  a 
tube,  formed  from  a  pedunculated  flap  obtained  from  the  prepuce,  was 
used  to  form  the  urethra. 

Mayo's  operation  is  performed  as  follows:  ''The  prepuce  is  stretched 
as  for  circumcision,  and  two  incisions  are  made  about  2.5  cm.  (i  inch) 
apart  extending  from  its  border  to  its  attachment  at  the  penile  cervix; 
the  prepuce  is  unfolded,  forming  a  loop  of  thin  skin  about  6.25  cm. 
(2I2  inches)  in  length.  Should  this  not  be  considered  sufficient  to 
reach  from  its  attachment  to  the  hypospadiac  opening,  the  two  incisions 
are  extended  back  along  the  dorsum  of  the  penis  until  sufficient  tissue 


SKIN 


URETHRAL 
OPENING 


j_     RAW 
*^  SURFACE 


AXIS  ON 
WHICH  PENIS 
IS  FOLD 


Fig. 


8. — Operation    for    hypospadias    (Bucknall). — i.  The    dotted    lines  indicate   the 
incisions  to  form  the  flaps.     2.  The  flaps  dissected  up  and  reflected. 


is  obtained,  where  the  two  incisions  are  connected  by  a  transverse  one, 
and  the  flap  of  skin  lifted  but  left  attached  to  the  cervLx  by  the  inner 
surface.  Several  sutures  now  close  the  lateral  integument  over  the 
denuded  area.  The  pedunculated  flap  of  prepuce  is  constructed  into 
a  tube,  with  its  skin  or  outer  surface  inside,  by  means  of  a  number  of 
catgut  sutures.  The  penis  is  tunneled  with  a  narrow  bistoury  or  me- 
dium trocar  and  cannula,  through  the  glans,  above  its  groove,  along  the 
penis  to  a  point  beneath  the  hypospadiac  opening,  when  it  is  made  to 
emerge  at  one  side  of,  but  close  to,  the  urethra;  the  tube  of  prepuce  is 
drawn  through  the  tunnel  and  sutured  where  it  enters  the  glans  and  also 


326 


PLASTIC    SURGERY 


NEW 
URETHRA 


-X    TRANS 
"l  SECTIONS 
-  (         OF 

J    RUBBER 
TUBE 

SCROTAL 
5KIN 


2  3 

Fig.  289. — Bucknall's  operation  for  hypospadias,  continued. — i.  Shows  the  penis 
fixed  to  the  scrotum,  and  the  flaps  held  together  by  sutures  passed  over  rubber  tubes.  The 
dotted  line  indicates  the  scrotal  flap  to  cover  the  under  surface  of  the  penis  when  it  is  dis- 
sected from  the  scrotum.  2.  Scheme  of  holding  flaps  together  by  means  of  suturing  over 
rubber  tubes.  3.  The  penis  is  raised  from  the  scrotum  and  the  raw  surface  covered  with 
skin  flaps.      The  broad  raw  area  on  the  scrotum  is  sutured. 


A  B 

Fig.  290. — Operation  for  hypospadias  (C.  H.  Mayo). — A.  i.  Scrotum.  2.  Glans 
penis.  3.  Raw  surface  after  raising  the  skin  for  the  new  urethra.  4.  Urethral  opening. 
5.  Skin  folded  to  form  a  tube.  B.  The  pedunculated  flap  5  folded  in  the  form  of  a  tube  is 
passed  through  a  perforation  in  the  glans,  and  through  a  tunnel  burrowed  in  the  skin  on 
the  under  surface  of  the  penis,  and  is  brought  out  near  the  old  urethra.  Later  the  pedicle 
is  cut  and  the  ends  of  the  tubes  are  joined. 


HYPOSPADIAS 


327 


where  it  emerges.  At  the  end  of  ten  days  the  pedicle  of  the  flap  is  cut 
through  close  to  the  new  meatus.  The  second  operation,  made  at  a 
later  period,  consists  of  a  perineal  opening  into  the  urethra  and  insertion 
of  a  Jacobs'  self-retaining  female  catheter;  this  is  the  least  irritating 
form  of  catheter  and  can  be  left  as  long  as  needed,  usually  from  five  to 
eight  days.  An  incision  at  the  termination  of  the  two  urethras  now 
admits  of  accurate  coaptation  by  sutures,  or  the  normal  urethra  may  be 
mobilized  (Beck's  method)  to  a  sufficient  extent  to  admit  of  its  inser- 
tion into  the  new  urethra,  where  it  is  held  by  sutures  and  the  external 


Fig.  291. — Operation  for  hypospadias  (Russell,  Annals  of  Surgery,  Aug.  1907). — i. 
The  penis  is  straightened  by  a  transverse  incision  which  divides  the  skin  and  all  contracting 
bands.  2.  The  dotted  lines  through  the  glans  indicate  the  channel  made,  which  should  be 
considerably  wider  than  is  shown.  The  dotted  lines  CC  and  DD' indicate  the  outlines  of 
the  double  pedicled  collar  flap  of  prepuce,  with  its  pedicle  between  C  and  D  on  each  side 
of  the  penis. 

parts  closed  over  this.  Occasionally  a  little  urine  escapes  into  the 
urethra,  and  the  entire  canal  is  best  drained  by  passing  several  strands 
of  silkworm  gut  or  horsehair  through  the  urethra  and  out  alongside  the 
catheter  in  the  perineal  opening"  (Fig.  290). 

Russell's  Operation.  First  Stage. — The  skin  binding  down  the 
penis  is  divided  fairly  near  the  glans  by  a  transverse  incision  which  may 
be  lengthened  as  much  as  needed.  Then  the  dense  fibrous  bands  holding 
down  the  penis  are  either  excised  or  divided  until  the  penis  is  completely 
released.  The  result  of  this  (when  the  penis  is  straightened)  will  be  a 
long  diamond-shaped  skin  defect.  A  channel  should  then  be  made 
through  the  glans  as  shown  in  the  diagram  and  the  surface  of  the  glans 


328 


PLASTIC    SURGERY 


denuded  for  a  short  distance  on  each  side  of  the  incision.  An  incision 
curving  sHghtly  upward  is  made  from  one  lateral  angle  of  the  defect 
on  the  penis  to  the  other,  across  the  dorsum  cc' ,  0.833  cm.  (3-^  inch) 
below  and  parallel  to  this  another  incision  dd'  is  made,  beginning  and 
ending  about  0.833  cm.  (3-^  inch)  from  the  raw  edge,  and  passing  slightly 


Fig.  292. — Russell's  operation  for  hypospadias,  continued. — i.   The  collar  flap  raised  and 
drawn  over  the  glans.      2.   The  flap  is  turned  inside  out  so  that  skin  is  against  skin. 

downward  at  the  extremities,  thus  giving  a  broad  pedicle  at  each  end  to 
the  flap.  The  flap  is  raised  from  its  bed  (care  being  taken  not  to  en- 
croach on  the  pedicles)  until  it  can  be  passed  over  the  end  of  the  penis 
a.  The  loop  is  turned  inside  out  so  that  skin  is  against  skin  and  drawn 
through  the  channel  in  the  glans  b  and  c.     The  loop  is  then  divided, 


Pig.  293. — Russell's  operation  for  hypospadias,  continued. —  i  and  2.  The  loop  is 
drawn  through  the  channel  in  the  glans.  3.  The  redundant  portion  of  the  loop  is  removed, 
and  the  edges  are  sutured  to  the  denuded  portion  of  the  glans  on  each  side  of  the  channel. 
All  wounds  are  then  closed. 

the  redundant  portion  is  removed,  and  the  edges  are  sutured  with  fine 
horsehair  to  the  denuded  surface  of  the  glans  on  each  side  of  the  incision, 
thus  preventing  subsequent  contracture  of  the  meatus  c.  The  wounds 
are  then  closed  with  horsehair.  A  self-retaining  catheter  is  placed  in 
the  urethral  opening  to  avoid  soiling  of  the  sutured  line  (Fig.  291-293). 


HYPOSPADIAS 


329 


Second  Stage. — This  should  not  be  done  for  some  months.  I 
have  waited  as  long  as  a  year.  Preliminary  to  the  formation  of  the 
rest  of  the  urethra  a  small  suprapubic  opening  should  be  made  in  the 
bladder  and  a  permanent  catheter  sewed  in.  (When  this  method  is 
used  for  a  complete  penile  defect,  an  external  urethrotomy  is  done.) 
In  order  to  understand  the  minute  details  of  the  second  stage  of  the 
operation  I  shall  quote  the  author  himself  in  part. 

"Starting  anteriorly,  note  in  Fig.  294,1  the  two  folds  of  skin  (AB, 
AC)  that  diverge  from  the  opening  of  the  glandular  urethra  to  be  lost 
in  the  body  of  the  penis.  These  are  guides  for  the  direction  of  incisions 
for  making  the  penile  urethra. 

Fig.  294,1  represents  this  region  enlarged  for  clearness  of  demonstra- 
tion.    A  is  placed  at  the  urethral  orifice  beneath  the  apex  formed  by  the 


I  2  3 

Fig.  294. — Russell's  operation  for  hypospadias,  continued. — i.  The  penile  portion  of 
the  new  urethra  is  at  the  point  A.  Slit  the  new  urethra  from  A  to  D,  and  remove  the  tissue 
in  the  area  DBAC.  2.  Result  of  the  excision.  The  dotted  lines  beginning  at  B  and  C 
indicate  the  upper  part  of  the  incisions  for  the  formation  of  the  penile  urethra.  3.  These 
incisions  are  continuous  with  the  line  BD  and  CB. 


two  folds  of  skin  AB,  AC.  Make  first  the  short  incision  AD  which 
slits  up  the  new  urethra  for  about  0.312  cm.  (i-g  inch).  This  will  make 
the  angular  flaps  DAB  and  DAC.  Mentally  complete  the  two  tri- 
angles DAB  and  DAC  by  the  dotted  lines  DB  and  DC. 

With  tine  forceps  and  scissors  remove  each  triangle  cutting  along 
the  base  lines  DB  and  DC.  Fig.  294,2  show^s  the  result  of  the  excision, 
and  the  cut  edges  of  the  two  layers  of  skin  of  which  the  folds  are  com- 
posed; the  inner  layer  is  part  of  the  preputial  loop  which  has  become 
the  lining  of  the  glandular  urethra;  the  outer  layer  is  continuous  with 
the  skin  of  the  body  of  the  penis. 

Start  the  lateral  incisions  for  the  penile  urethra  from  the  points 
B  and  C  respectively,  and  carry  them  down  the  penis  as  indicated  by  the 
dotted  lines  (Fig.  294,2).     It  is  clear  that  the  penile  urethra  will  be  con- 


3S° 


PLASTIC    SURGERY 


tinuous  with  the  glandular  portion  (Fig.  294,3).  We  now  turn  to  the 
perineum  and  draw  apart  the  cleft  scrotum  and  observe  the  two  follow- 
ing landmarks,  which  are  represented  enlarged  and  very  diagrammat- 
ically  in  Fig.  295,1. 

(i)  The  fine  ridge  or  crest  (aa'),  which  separates  the  mucous 
membrane  of  the  perineal  urethra  abruptly  from  the  skin  of  the  peri- 
neum. (Note  that  I  wish  AA'  to  indicate,  not  the  short  straight 
line  at  the  anterior  extremity  of  the  urethra,  but  the  long  U-shaped  AA' 
that  passes  backward  round  the  urethral  orifice,  and  forward  again,  as 
indicated  by  the  Httle  arrows  in  the  diagram.) 


B        B' 


123 

Fig.  295. — Russell's  operation  for  hypospadias,  continued. —  i.  The  line  AA'  indicates 
the  fine  ridge  which  separates  the  mucous  membrane  of  the  perineal  urethra  from  the  skin 
of  the  scrotum.  The  surface  line  of  the  skin  of  the  perineum  BB'  overlaps  the  urethral 
opening  at  its  lowest  point.  2.  The  overlapping  portion  is  released  by  a  short  median 
incision  which  exposes  the  lower  portion  of  the  perineal  urethra  and  forms  a  small  quadri- 
lateral raw  surface  as  is  indicated  by  the  shaded  area.  3.  The  shaded  area  indicates  the 
amount  of  skin  excised  around  the  perineal  mucous  membrane.  Note  that  the  skin  adjacent 
to  the  upper  fourth  of  the  mucous  membrane  is  not  disturbed,  as  otherwise  undue  narrow- 
ing of  the  urethra  would  follow. 


(2)  The  surface  line  of  the  skin  of  the  PERiNEUMn  (bb'), 
Fig.  295,1,  which  overlaps  AA'  posteriorly  more  than  is  show  in  the 
diagram.  Between  these  two  lines,  A  A'  and  BB',  there  is  an  area  of 
skin,  broad  behind  and  gradually  narrowing  anteriorly,  that  is  to  be 
removed,  leaving  a  raw  surface.  Proceed  as  follows:  a  short  median 
incision  backward  through  the  skin  only,  so  as  to  completely  expose  to 
view  the  hinder  part  of  the  perineal  urethra  and  the  existing  orifice. 
This  incision  will  create  the  small  quadrilateral  raw  surface  shown  in 
Fig.  295,2. 

Separate  accurately  the  perineal  mucous  membrane  from  the  skin, 
along  the  U-shaped  line  AA'.  A  good  way  to  do  this  is  to  take  fine 
scissors  and  clip  away  the  thin  crest  that  separates  mucous  membrane 
from  skin  along  the  line  AA'.     Note  that  this  procedure  must  be  carried 


HYPOSPADIAS 


33^ 


forward  only  so  far  as  to  the  point  where  the  dotted  lines  meet  the 
perineal  urethra  (Fig.  295,2  CC')-  At  this  point  the  mucous  membrane 
must  be  left  and  the  demarcation  continued  forward  in  the  form  of  an 
incision  along  the  dotted  lines  (CC).  This  is  to  obviate  undue  narrow- 
ing of  the  urethra,  with  which  we  are  threatened  at  this  spot.  The 
line  of  separation  between  urethra  and  other  structures  having  been 
thus  laid  down,  dissect  away  all  the  skin  intervening  between  AA'  and 
BB',  as  indicated  by  the  shading  in  Fig.  295,3.  This  will  leave  a  broad 
raw  surface  in  the  perineum,  narrowing  as  it  passes  forward. 


Fig.  296. — Russell's  operation  for  hypospadias,  continued. — i.  The  glandular  urethra 
completed.  The  central  flap  of  skin  is  separated:  stitches  are  placed  which  will  infold  the 
central  flaps  to  line  the  urethra,  and  cover  it  with  skin.  2.  The  sutures  tied  and  new 
urethra  completed. 

The  operator  must  now  strike  a  hne  for  the  lateral  incisions  that 
have  been  already  made  in  the  penile  portion.  In  doing  this,  he  for 
the  first  time  seems,  as  it  were,  to  leave  the  track  and  travel  across 
country  through,  it  may  be,  rather  doubtful  looking  scrotal  tissue. 
He  must  just  plan  his  incisions  so  as  to  make  the  junction  of  the  penile 
with  the  perineal  urethra  uniform  in  calibre  with  the  rest.  Although 
this  has  been  the  only  point  in  the  procedure  at  which  I  have  experienced 
some  feeling  of  uncertainty,  healing  has  been  quite  satisfactory  in  this 
part  in  both  my  cases. 

The  entire  length  of  the  new  urethra  has  now  been  marked  out. 
The  skin  composing  it  is  now  to  be  carefully  raised  on  either  side,  work- 
ing toward  the  median  line,  sufficiently  to  permit  it  to  fold  easily  over 


zz^ 


PLASTIC    SURGERY 


to  make  the  new  urethra,  without  the  least  tension.     All  is  now  ready 
for  the  suturing. 

Fig.  296,1.  The  new  urethra  and  the  skin  of  the  penis  are  now 
brought  together  throughout  by  a  series  of  sutures.  Each  suture 
includes  four  layers  of  skin,  the  needle  passing  in  order  through  outer 
skin  and  urethral  skin  of  one  side,  then  through  the  urethral  skin  and 
outer  skin  of  the  other.  I  need  not  dwell  on  the  necessity  for  extreme 
delicacy  and  accuracy  in  the  performance  of  this  final  step  of  the  opera- 


FiG.  297. — Perineal  hypospadias.  Patient  24  years  old.  No.  5559. — The  urethral 
opening  is  about  on  the  level  with  the  cross  mark.  The  testicles  are  apparently  normal. 
The  scrotum  is  bifid  and  the  penis  which  is  markedly  curved  forward,  is  considerably  smaller 
than  normal. 

tion  on  the  penile  portion  of  the  urethra,  which  is  the  only  part  of  the 
operation  in  which  the  result  is  at  all  precarious.  The  perineal  por- 
tion, where  the  surface  is  broad,  scarcely  needs  any  suturing;  the  sutures 
there  will,  of  course,  just  miss  the  mucous  membrane. 

Fig.  296,2  shows  the  operation  completed.'' 

The  objection  to  this  operation  is  that  hair  will  probably  grow  on 
the  scrotal  skin  which  is  used  to  form  the  lower  half  of  the  urethra. 


HYPOSPADIAS 


333 


METHOD  OF  CHOICE 

I  prefer  Russell's  method  of  forming  the  glandular  urethra,  and 
have  done  a  number  of  cases  in  this  way  without  a  single  failure.  It 
is  somewhat  difhcult  to  understand  the  application  of  the  flaps,  but 
once  understood,  it  is  in  my  opinion  the  best  method  as  yet  devised. 


Fig.  298. — Perineal  hypospadias,  conlinued. — The  result  of  several  operations.  The 
penis  was  straightened  and  the  urethra  in  the  glans  was  made  by  Russell's  method.  The 
penile  and  perineal  urethra  was  formed  by  a  modified  Duplay  operation,  and  then  the 
newly  formed  sections  of  the  urethra  were  joined.  Several  months  were  allowed  to  elapse 
between  each  operation.  The  photograph  shows  the  operation  completed,  and  with  a  No. 
26  sound  (French)  passing  through  the  newly  formed  urethra  into  the  bladder. 

The  formation  of  the  flaps  in  this  way  is  very  satisfactory,  and  can 
be  used  in  the  complete  penile  as  readily  as  in  the  perineal  type.  I 
sometimes  use  the  Duplay  method  for  forming  the  penile  urethra.  Xo 
satisfactory  way  has  been  devised  to  avoid  the  use  of  scrotal  skin  in 
forming  the  perineal  urethra  below  the  penoscrotal  junction,  and  as 
the  growth  of  hair  is  the  main  objection  to  its  use  I  would  suggest  that 
the  hair  follicles  be  destroyed  with  radium  or  .v-rays  (after  carefully 
protecting  the  testicles)  before  the  operation  is  done. 


334 


PLASTIC    SURGERY 


In  suturing  the  flap  which  is  to  be  the  Hning  of  the  urethra,  I  prefer 
to  close  this  with  a  separate  line  of  sutures  over  a  rubber  tube,  rather 
than  to  use  the  same  sutures  for  both  flaps.  If  possible  the  flaps  should 
be  arranged  so  that  the  suture  lines  will  not  be  superimposed. 

When  closing  the  defect  on  the  penis  after  construction  of  anew 
urethra,  if  lateral  flaps  cannot  be  utilized,  I  often  employ  pedunculated 
flaps  from  the  scrotum. 

For  buried  sutures  very  fine  catgut  is  satisfactory.  For  the  skin 
I  prefer  horsehair. 


12  3  4 

Fig.  299. — Hypospadias.  Patient  7  years  old. — i  and  2.  The  arrow  indicates 
the  position  of  the  urethral  opening.  There  is  a  groove  in  the  glans.  The  penis  is  bent 
forward.  The  testicles  are  normal.  Note  the  redundant  prepuce.  3.  The  result  of  the 
formation  of  the  urethra  in  the  glans  by  Russell's  method,  and  the  upper  portion  of 
the  glandular  urethra  by  Duplay's  method  (the  lower  portion  broke  down).  Note  the 
probe  passed  through  the  urethra  and  the  position  of  the  penis,  which  was  straightened  at 
the  first  operation.  4.  Completion  of  the  urethra.  A  flexible  catheter  has  been  passed 
through  the  urethra  into  the  bladder.  The  outside  surface  of  the  lower  portions  of  the 
urethra  is  made  from  a  scrotal  flap. 


The  tube  over  which  the  new  urethra  is  formed  should  not  be  allowed 
to  remain  in  place  for  longer  than  24  hours.  Most  operators  prefer 
to  remove  it  immediately,  but  in  some  instances  its  retention  for  this 
period  is  distinctly  advantageous. 

Bladder  irrigation  with  normal  salt  solution  must  be  used  every 
day  when  a  permanent  catheter  is  necessary.  Urotropin  by  mouth  is 
also  useful  to  prevent  bladder  infection. 

All  operations  for  hypospadias,  except  in  the  mild  cases,  are  done  in 
stages.     When  the  stitches  tear  out  or  infection  occurs,  the  result  may 


HYPOSPADIAS  335 

not  be  completely  successful  the  first  time,  and  it  may  be  necessary  to 
perform  quite  a  number  of  secondary  operations  to  close  those  portions 
of  the  suture  line  which  have  not  held.  This  repair  should  never  be 
attempted  until  healing  is  complete,  and  all  induration  has  disappeared. 

Following  any  method  of  repair  it  is  necessary  gradually  to  dilate 
the  newly  formed  urethra  with  sounds,  until  the  urethra  will  take  a  No. 
26  to  30  F.  in  an  adult,  and  a  No.  16  to  20  F.  in  a  child. 

The  ultimate  test  of  the  success  of  an  operation  is  the  ability  of  the 
patient  to  urinate  normally,  and  to  have  a  straight  erection. 

BIBLIOGRAPHY 

Beck,  C.     "Surg.,  Gyne.  &  Obst.,"'  May,  1917,  511. 

Bevax,  a.  D.     "Jour.  Amer.  Med.  Assn.,"  April  7,  191 7,  1032. 

BixxiE,  J.  F.     "Operative  Surgery,"  7th  Ed.,  727. 

BucKXALL,  R.  T.  H.     "Lancet."     London,  Sept.  28,  1907,  887. 

Caxtas,  M.     "Lyon  Chir.,"  ^larch,  1911,  v,  250. 

DuPLAY,  S.     "Ashhurst's  Internat.  Encjxl.  Surg.,"  1886,  vi,  487. 

GiAXTURCO,  G.     "Riforma  Med."     Naples,  Feb.  23,  1918,  xxxiv,  147. 

Legueu,  F.     "Presse  med."     Paris,  March  30,  191  6. 

"Jour,  of  Urology."     Baltimore,  Oct.,  1918,  369. 

M.\YO,  C.  H.     "Jour.  Amer.  Med.  .\ssn.,"  April  27,  1901,  1157- 

N6\'E-JossERAXT).     "Archiv  Gen.  de  Chir."     Paris,  April,  1909,  No.  4. 
"J.  d'urol.,"  1914,  V,  393. 

Rochet.     "Gaz.  hebd.  de  med."     Paris,  1899,  n.  s.  iv,  673. 
RowLAXDS  &  TuRXER.     "Jacobson's  Operations  of  Surgery,"  ii,  21. 
Russell,  R.  H.     "Anns.  Surg.,"  1907,  -xlvi,  244. 

ScHMiEDEX.     "Archiv  f.  klin.  Chir.,"  xc,  Hft.  3,  1909. 
Streissler,  E.     "Arch.  f.  klin.,"  6th  Ed.     Berlin,  1911,  -xcv,  663. 

Taxtox.     "Presse  Med."     Paris,  Jan.  27.  1909. 
Thompsox,  J.  E.     "Surg.,  Gyne.  &  Obst.,"  Oct.,  1917,  4ii- 

Vax  Hook,  \V.     "Anns.  Surg.,"  1896,  x.xiii,  378. 

White  axd  Martix.     "  Genito-urinary  Surgery  and  Venereal  Diseases,"  loth  Ed.,  191 7 
144- 


CHAPTER  XV 
ATRESIA  OF  THE  VAGINA 

We  are  interested  here  only  in  complete  atresia  of  the  vagina. 
The  problem  presented  by  cases  in  which  the  lower  end  of  the  outlet 
only  is  implicated  are  distinctly  gynecological. 

Our  cases  fall  into  tiro  groups:  (i)  Acquired  atresia,  due  to  trauma, 
operation,  infection,  or  severe  cauterization.  Since  the  uterus  and 
appendages  are  usually  present,  the  formation  of  a  canal  is  almost 
always  essential  for  the  evacuation  of  the  menstrual  blood.  (2) 
Congenital  atresia,  due  to  arrested  development.  In  these  cases  the 
uterus  and  appendages  are  either  missing,  or  are  rudimentary  in  char- 
acter. Both  of  these  groups  are  rare,  but  in  Marshall's  experience 
the  congenital  type  has  occurred  more  frequently  than  the  acquired. 

It  is  very  difficult  in  some  instances  to  differentiate  between  a  male 
pseudo-hermaphrodite  with  female  development  and  a  female  with 
atresia.  This  point  must  be  carefully  taken  into  consideration  before 
an  operation  for  forming  an  artificial  vagina  is  undertaken. 

In  instances  in  which  there  has  been  no  collection  of  menstrual 
blood  the  defect  may  not  be  discovered  until  after  marriage;  in  others 
the  defect  is  discovered  earlier,  and  the  patients  insist  that  something 
be  done  before  marriage  can  be  considered.  In  view  of  the  fact  that  a 
birth  canal  will  never  be  needed,  we  have  to  decide  whether  it  is  advisa- 
ble in  the  particular  case  to  make  a  vagina  solely  for  the  purpose  of 
sexual  intercourse. 

In  some  cases  after  the  defect  is  discovered  the  mental  attitude 
of  the  patient  is  such  that  surgical  intervention  becomes  inevitable. 
In  others  the  formation  of  a  vagina  may  be  essential  for  a  continuation 
of  marital  happiness. 

The  ethics  in  such  cases  have  been  the  subject  of  a  good  deal  of  dis- 
pute. The  operation  should  be  undertaken  only  after  mature  con- 
sideration of  all  the  various  phases  of  each  case. 

There  are  two  general  methods  of  operative  procedure  which  have 
given  some  measure  of  success,  (ij  The  formation  of  a  vagina  by  the 
use  of  pedunculated  skin  flaps  from  the  labia  and  skin  of  the  thigh. 
This  procedure  has  been  successfully  carried  out  by  Heppner,  Roux, 

336 


ATRESIA    OF    THE   VAGINA 


337 


Picque,  Vautrin,  Ferguson,  Beck,  Graves,  Juvara,  and  others.  The 
method  of  Graves  is  probably  the  best  of  the  skin  flap  operations,  and 
the  steps  are  well  shown  in  the  diagrams  (Fig.  300). 

Skin  grafts  have  been  used  by  Abbe,  Forgues,  Isaac,  Tuffier,  and 
others,  and  mucous  membrane  grafts  (iso-vaginal  mucosa)  by  Hirst, 
Kiistner,  and  Mackenrodt,  to  line  the  cavity  burrowed  between  the 
bladder  and  rectum.     Flaps  of  peritoneum  (Stokelj  have  been  used, 


Fig.  300. — Operation  for  congenital  absence  of  the  vagina  (Graves). — i.  Through  a 
transverse  incision  below  the  urethra  a  cavity  of  the  desired  size  is  burrowed  between  the 
bladder  and  rectum  (care  being  taken  not  to  enter  the  abdominal  cavity.)  This  pocket 
is  then  lined  by  means  of  four  pedunculated  flaps.  The  labium  minus  on  each  side  is 
dissected  oS  from  above  downward  in  such  a  manner  as  to  leave  a  pedicle  sufficiently  large 
to  assure  the  circulation.  The  two  surfaces  are  then  split  apart  so  that  two  paddle-shaped 
flaps  are  formed.  A  flap  is  raised  from  the  inner  side  of  each  thigh  with  bases  at  the  two 
lower  corners  of  the  artificial  opening.  All  four  flaps  are  sutured  together  over  a  glass  form, 
skin  side  outward.  Before  the  flaps  are  sewed  together  four  catgut  sutures  with  the  ends 
left  long  should  be  olaced  in  the  vault  of  the  artificial  cavity.  2.  When  the  suturing  of 
the  edges  is  nearly  complete  the  glass  form  is  taken  out,  and  the  long  catgut  sutures 
mentioned  above  are  brought  out  through  the  skin  pouch.  The  pouch  is  then  inverted,  the 
sutures  are  tied  and  the  cavitj-  is  packed. 


and  also  the  lining  of  hernia  sacs  (Dreyfus).  By  none  of  these  methods, 
however,  has  a  really  satisfactory  vagina  been  obtained,  on  account  of 
the  tendency  ever  present  to  contraction,  which  in  the  majority  of  these 
cases  cannot  be  overcome. 

(2)  The  Formation  of  a  Vagina  by  Means  of  Intestinal  Trans- 
plantation.— Sneguireff,    a   Russian,  lirst  suggested    the    method    and 


338 


PLASTIC    SURGERY 


transplanted  the  lower  part  of  the  rectum  to  form  the  vagina, 
and  the  upper  to  form  a  sacral  anus.  He  reported  three  cases  up  to 
1904.  In  the  same  3^ear,  in  this  country,  Baldwin  suggested  his  method 
of  transplanting  a  double  loop  of  ileum,  and  since  that  time  practically- 
all  of  the  successful  work  on  these  cases  has  been  done  by  his  method, 
or  some  modification  of  it. 

The  sigmoid  (Albrecht),  and  rectum  (Schubert,  Strassman,  Amann, 
and  others),   have  been  used.     The  use  of  the  ileum — either  double 


Fig.  301. — Baldwin's  operation  for  the  creation  of  a  vagina  (Quenu  and  Schwartz). — 
The  diagram  shows  the  formation  of  a  vagina  by  a  double  loop  of  ileum  with  its  pedicle  of 
mesentery  brought  down  and  sutured  to  the  skin  margins  of  a  channel  burrowed  between 
the  rectum  and  bladder.  The  septum  between  the  loops  is  divided  subsequently.  A.  The 
double  loop  of  bowel  with  its  apex  opened  and  sutured  to  the  skin  edges.  B.  Rectum. 
C.  Bladder.  D.  Mesenteric  pedicle.  E.  The  ends  of  the  ileum  anastoinosed  laterally. 
(Baldwin  in  his  original  operation  used  an  end-to-end  anastomosis  with  a  Murphy  button.) 


or  single  loops  (Mori,  Stewart,  Wallace,  Abbott,  and  others) — offers 
the  most  rational  method,  and  quite  a  few  good  and  lasting  results 
have  been  reported. 

Technic  of  Baldwin's  Operation. — "With  the  patient  in  the  lithotomy 
position,  through  an  incision  between  the  labia,  the  bladder  and  rectum 
are  carefully  separated  until  the  peritoneum  is  opened.  (The  new 
canal  should  be  made  sufficiently  large.)  After  the  canal  has  been 
packed  the  patient  is  put  in  the  horizontal  position,  and  the  abdomen 
is  opened  by  a  low  midline  incision.  The  operator  then  selects  a  coil 
of  ileum  (quite  close  to  the  cecum),  on  account  of  its  long  mesentery, 
always  making  sure  that  the  double  loop  will  be  long  enough  to  reach  the 


ATRESIA    OF    THE   VAGINA 


339 


vaginal  outlet  without  tension.  He  isolates  the  coil  with  its  mesentery 
attached  and  turns  the  ends  in.  He  then  makes  an  end-to-end 
or  a  lateral  anastomosis  to  reestablish  the  continuity  of  the  ileum 
(Baldwin  uses  a  ]\Iurphy  button  for  this  anastomosis).  The  double 
loop  of  isolated  bowel  is  drawn  down  into  the  opening  between  the 
bladder  and  rectum  with  a  long  pair  of  forceps  passed  up  through  this 
opening,  until  the  apex  of  the  loop  is  seen  beyond  the  skin  margin. 
The  peritoneum  is  then  closed  around  the  mesentery  and  the  abdomen 
is  closed.  The  apex  of  the  loop  of  the  intestine  is  divided  and  the 
edges  are  sutured  to  the  skin,  just  enough  packing  being  placed  in  each 
loop  to  hold  it  in  approximation  with  the  surrounding  walls.     The 


Fig.  302. — Operation  of  A.  Schwartz  for  the  creation  of  a  vagina  (Quenu  and 
Schwartz). — The  diagram  shows  the  formation  of  a  vagina  by  utilizing  a  loop  of  ileum. 
The  operation  differs  from  Baldwin's  in  that  the  upper  loop  is  quite  short.  This  gives  the 
advantage  of  a  large  orifice  without  sacrificing  so  much  bowel.  A.  New  vagina.  B 
Rectum.  C.  Bladder.  D.  Mesenteric  pedicle.  E.  Lateral  anastomosis  of  ends  of 
ileum. 

packing  should  be  removed  from  time  to  time,  and  the  stitches  after 
14  days  (Fig.  301). 

In  this  way  a  double  vagina  is  formed.  The  septum  between  the 
two  canals  can  be  divided  after  a  few  weeks,  and  healing  will  be  prompt. 
The  results  reported  by  a  number  of  operators  are  good.  The  vagina  is 
large  and  shows  no  tendency  to  contract.  If  the  uterus  is  in  good  condi- 
tion the  upper  loop  of  bowel  can  be  placed  around  the  cervix  so  that 
the  menstrual  flow  will  not  be  impeded. 

These  operations  are  of  considerable  severity,  and  should  never  be 
undertaken  until  the  dangers  have  been  fully  explained  to  the  patient. 


340 


PLASTIC    SURGERY 


Fig.  303. — Operation  for  the  creation  of  a  vagina  (F.  T.  Stewart;  Annals  of  Surgery, 
Feb.,  1913). — The  segment  of  ileum  CDE  is  isolated.  The  ends  A  and  B  are  united  by  end- 
to-end  anastomosis.  The  ends  C  and  D  are  ligated  and  invaginated.  The  mesentery 
along  the  distal  half  C  to  E  tied  and  cut.  The  end  C  is  drawn  out  between  the  bladder  and 
rectum,  the  bowel  at  E  attached  to  the  vulval  orifice,  and  the  excess  from  C  to  E^cut  off. 


Fig.  304. — Mori's  operation  for  the  creation  of  a  vagina  (Quenu  and  Schwartz). — 
Diagram  showing  formation  of  a  vagina  by  a  single  loop  of  ileum.  The  open  end  of  the 
loop  is  sutured  to  the  skin  edges  of  the  channel  burrowed  between  the  bladder  and  rectum. 
A.  New  vagina.  B.  Rectum.  C.  Bladder.  D.  Mesenteric  pedicle.  E.  Lateral* anas- 
tomosis of  ileum. 


ATRESIA    OF    THE   VAGINA  34I 

Guggisberg  reports  a  death  following  gangrene  of  a  piece  of  bowel 
transplanted  by  Baldwin's  method.  This  accident  emphasizes  the 
importance  of  preserving  the  blood  supply  of  the  loops  of  bowel  until 
the  new  blood  supply  is  assured. 

The  double  loop  has  the  following  advantages:  (a)  it  forms  a  much 
larger  vagina;  (b)  it  provides  a  better  blood  supply;  (c)  with  it  we  avoid 
any  subsequent  dilatation  so  often  necessary  when  the  single  loop  is 
employed. 

Marshall  has  collected  a  number  of  cases  of  pregnancy  following  the 
formation  of  a  new  vagina,  mostly  by  plastic  methods,  but  my  under- 
standing is  that  none  of  these  were  cases  of  complete  atresia.  In  the 
great  majority  of  cases  the  new  vagina  is  constructed  to  prevent  marital 
unhappiness  or  mental  instability  in  the  patient. 

BIBLIOGRAPHY 

Abadie,  J.     "Revue  de  Gyne."     Paris,  1911,  xvi,  i. 

Abbe,  R.     "Med.  Rec."     New  York,  1898,  836. 

Abbott,  A.  W.     "Trans.  Western  Surg.  Assn.,  Jour.  Amer.  IMed.  Assn.,"  Feb.  2,  1918,  341. 

"Surg.,  Gyne.  &  Obst.,"  Aug.,  1918,  227. 
.\i.BRECHT.     "Deutsche  Ztschr.  f.  Chir.,"  June,  1913. 
.\manx,  J.  A.     "Monatschr.  f.  Geburtsh.  und  Gyna."     Berlin,  May,  191 1. 

Baldwin,  J.  F.     ".\nns.  Surg.,"  Sept.,  1904,  398. 

"Amer.  Jour.  Obst.,"  1907,  Ivi,  636. 

"Jour.  Amer.  Med.  Assn.,"  April  23,  1910,  1362. 

"Med.  Rec."     New  York,  Dec.  28,  191 2. 
Beck,  C.     "Anns.  Surg.,"  1900,  xxxii,  572. 
BOLDT,  H.  J.     "Jour.  Amer.  Med.  Assn.,"  Jan.  24,  1914,  327. 

"Amer.  Jour.  Obst.,"  March,  1914. 

Dreyfus.     "La  Gyn.,"  April,  191 2. 

"Jour.  Obst.  &  Gyn.,"  1912,  xxi,  353. 

Ferguson,  \.  H.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  191 1,  182. 

FoRGUES.     Cited  by  Marshall :  "Jour.  Obst.  &  Gyn.  of  British  Empire."     London,  .April, 

1913- 

Gr.wes.     "Boston  Med.  &  Surg.  Jour.,"  Nov.  17,  1910,  753. 
GuGGiSBERG,  H.     "Zent.  f.  Gyne."     Leipsic,  Nov.  20,  1915,  47- 

Heppner.     "St.  Petersburg  Med.  Wochenschft.,"  1892,  Heft  2. 
Hirst.     "  Diseases  of  Women,"  1903,  145. 

Isaac.     Cited   by  Marshall:  "Jour.  Obst.  &  Gyn.  of  British  Empire."     London,  April, 
1913- 

Juvara,  E.     "Revue  de  Gyn."     Paris,  May,  191 2. 


342 


PLASTIC    SURGERY 


Kerr,  J.  M.  M.     "Surg.,  Gyne.  &  Obst.,"  May,  1914,  621. 
KtJSTNER.     "Zentralbl.  f.  Gyn.,"  1895,  Nr.  30. 

"Zeitschft.  f.  ged.  und  Gyn.,"  xviii. 

"Lehrbuch  f.  Gyn.,"  1908,  88. 

Mackenrodt.     "Zeit.  f.  ged.  und  Gyn.,"  xxxvi,  530. 

"Zentralbl.  f.  gyn.,"  1896,  Nr.  21. 
Marshall,  G.  B.     "Jour.  Obst.  &  Gyne.  of  British  Empire."    London,  April,  1913,  193. 

(Extensive  bibliography.) 
Mori.     "Zentralbl.  f.  Gyn.,"  1909, 172. 

"Zentralbl.  f.  Gyn.,"  1910,  11. 

PiCQUE.     "Ann.  de  Gyn.  et  d'Obst.,"  1890,  124. 
Pozzi,  S.     "Revue  de  Gyn."     Paris,  191 1,  xvi,  269. 

QuENU,  E.  &  A.  Schwartz.     "Revue  de  Chir.,"  June,  1913,  855. 

Roux,  E.     "Revue  de  Gyn.,"  1908,  xii,  mo. 

Schubert,  G.     "Zentralbl.  f.  Gyn."    Leipsic,  July  15,  191 1. 

"Zentralbl.  f.  Gyn."     Leipsic,  Feb.  17,  191 2. 

"Zentralbl.  f.  Gyn."     Leipsic,  Aug.  24,  1912. 

"Surg.,  Gyne.  &  Obst.,"  1914,  xix,  376. 
Sneguireff.     "Zentralbl.  f.  Gyn."    Leipsic,  1904,  Nr.  24,  772. 
Stewart,  F.  T.     "Anns.  Surg.,"  Feb.,  1913,  210. 
Stockel,  W.     "Zentralbl.  f.  Gyn."    Leipsic,  Jan.  6,  191 2. 
Strassman,  p.     "Zentralbl.  f.  geb.  und  Gyn.,"  Ixvi,  Nr.  i. 

TuFFiER.     "Bull,  et  mem.  soc.  de  chir.  de  Par.,"  1904,  n.  s.  595. 

Vautrin.     "Annal  de  Gyn.  et  d'obst.,"  Feb.,  1905. 
"Jour,  of  Obst.  and  Gyn.,"  1905,  viii,  47. 

Wallace,  W.  L.  "Buffalo  Med.  Jour.,"  Feb.,  1911,  364. 
Ward,  W.  D.  "Surg.,  Gyne.  &  Obst.,"  Nov.,  1915,  655. 
Wright,  T.     "Buffalo  Med.  Jour.,"  Dec,  1913. 


CHAPTER  XVI 

PLASTIC  SURGERY  AS  APPLIED  TO  THE  VARIOUS 

REGIONS 

GENERAL   CONSIDERATIONS 

In  considering  the  operative  treatment  for  the  relief  of  deformities 
of  the  various  regions  of  the  body,  I  shall  not  attempt  to  describe  the 
multitudinous  operations  which  have  been  de\-ised.  My  endeavor  will 
be  to  consider  only  those  whose  principles  are  correct  and  which  have 
been  of  use  to  me  at  one  time  or  another.  ^lany  of  the  fundamental 
ideas  on  which  all  well-planned  plastic  operations  are  based  were 
described  years  ago  and  some  of  the  original  operations  have  yet  to  be 
improved  upon.  It  is  seldom  that  we  have  a  case  which  is  exactly 
the  counterpart  of  the  model  on  which  the  operative  description  is 
based,  so  that  it  is  often  impossible  to  make  the  incisions  as  described. 
When  in  doubt  as  to  the  best  method  for  any  particular  case,  my  own 
procedure  is  to  look  over  a  number  of  operative  suggestions  and  combine 
the  points  best  suited  to  that  particular  case.  Some  of  these  operations 
are  of  considerable  complexity,  and  an  accurate  description  is  most 
difficult.  Nevertheless,  with  the  aid  of  diagrammatic  drawings  the 
general  methods  of  procedure  may  be  understood  and  utilized. 

The  vast  majority  of  plastic  operations  in  civil  practice  have  for 
this  object  the  correction  of  old  defects  due  to  trauma,  burns,  or  neces- 
sarily mutilating  operations.  A  certain  number  of  cases,  such  as  defects 
left  by  the  radical  removal  of  carcinoma  of  the  lip.  should  be  repaired 
at  once.  In  war  surgery  much  can  be  accomplished  by  proper  early 
care,  but  many  of  the  final  results  shown  in  published  articles  could  be 
vastly  improved  by  subsequent  plastic  work. 

The  mental  attitude  of  a  certain  group  of  patients  who  appeal  to 
the  plastic  surgeon  to  correct  very  shght  or  imaginary  deformities 
of  the  face  must  be  given  careful  consideration.  These  patients  are 
often  suffering  from  melancholia  with  a  suicidal  tendency,  and  should 
be  brought  under  the  influence  of  a  skilled  psychiatrist.  Operative 
treatment  should  be  discouraged  in  this  group,  and  avoided  if  in  any 
way  possible,  because  in  the  end.  no  matter  now  perfect  it  may  be.  the 
result  is  rarely  satisfactory  to  such  a  patient. 

343 


344 


PLASTIC    SURGERY 


I 


I 


Pig.  305. — Arteries  of  the  skin  of  the  head  and  neck  (Manchoi).  p.  Subcutaneous 
branches  from  the  parotid,  sm.  Cutaneous  branches  of  the  submental  artery,  cd.  De- 
scending cervicals  from  the  occipital  artery,  cs.  Cutaneous  branches  of  the  superficial 
cervical  artery.  Ic.  Cutaneous  branches  of  the  transversalis  colli  artery,  ts.  Cutaneous 
branches  of  the  suprascapular  artery,  ts' .  Subcutaneous  supraclavicular  artery,  ra,  rp. 
Anterior  and  posterior  branches  of  the  supraclavicular  artery,  raa.  Anterior  auricular 
branches,     rap.   Posterior  auricular  artery. 


AS    APPLIED    TO    THE   VARIOUS    REGIONS  345 

SURGERY  OF  THE  SCALP  AND  SKULL 
SCALP 

Plastic  surgery  of  the  scalp  has  to  do  with  the  repair  of  extensive 
defects  due  to  operation,  trauma,  burns,  disease,  or  infection. 

The  scalp  extends  from  the  superciliary  ridges  in  front  to  the  superior 
curved  line  of  the  occipital  bone  behind  and,  on  the  sides,  to  the  tem- 
poral ridges.  It  consists  of  the  skin  and  subcutaneous  tissue,  the 
occipito-frontalis  muscle  and  its  aponeurosis. 

AVULSION  OF  THE  SCALP  ^ 

The  most  extensive  lesions  are  those  caused  by  avulsion  of  the  scalp. 
In  complete  scalping  the  whole,  or  a  portion  of  the  scalp  is  entirely 
separated  from  the  cranial  vault  and  the  adjacent  skin.  In  the  incom- 
plete variety  (which  w^e  shall  not  consider),  the  scalp  is  not  entirely 
separated,  but  is  left  attached  by  a  pedicle. 

Etiology. — In  the  great  majority  of  cases  avulsion  of  the  scalp  is 
an  industrial  accident  and  the  victims  are  females.  The  usual  history 
is  that  the  hair  is  caught  on  a  rapidly  revolving  shaft  and  the  force  of 
the  machine  and  speed  of  rotation  is  opposed  by  the  weight  of  the  body 
and  the  struggles  of  the  victim. 

The  line  of  separation  is.  as  a  rule,  at  the  junction  of  the  scalp  with 
the  skin  of  the  neck  and  face,  or  in  other  words  where  it  is  thinnest. 
The  amount  avulsed  varies  with  the  amount  of  hair  caught  and  the  dura- 
tion and  intensity  of  the  force.  Besson  says  that  if  the  hair  is  caught  at 
the  back,  the  skin  in  front  is  torn  first;  if  caught  in  front,  the  occipital 
region  yields  first;  if  caught  on  the  top,  the  skin  yields  at  the  vertex  and 
tears  down  to  the  ear  on  that  side;  when  all  the  hair  is  caught  at  once 
the  tearing  begins  at  the  eyebrows,  following  the  line  along  the  zygoma, 
around  or  through  the  ears,  and  finishes  low^  on  the  neck  (Figs.  306- 

309)- 

P.\iN. — It  is  interesting  that  pain  is  rarely  complained  of  at  the  time 
of  the  accident  and  fortunately  in  most  cases  there  is  little  pain  later, 
so  that  dressings  are  not  especially  trying. 

Hemorrhage. — The  bleeding  may  for  a  short  time  be  very  profuse 
and  then  cease;  and  a  temporary  anemia  may  result.     In  many  cases 

'  For  a  full  discussion  of  the  subject  of  scalping,  see  J.  S.  Davis,  Johns  Hopkins  Hospital 
Reports,  vol.  xvi.  Since  the  publication  of  that  paper  a  number  of  additional  cases  of 
scalping  have  appeared  in  the  literature,  but  there  has  been  no  improvement  in  the  method 
of  treatment. 


346 


PLASTIC    SURGERY 


the  shock  is  surprisingly  slight,  but  occasionally  there  is  complete 
collapse. 

Complications   may   be   divided   into    three   groups:    (i)    Those 
which  occur  at  the  time  of  the  accident,  such  as  fractures,  and  other 


1234 

Pig.  306. — Complete  scalping.  Healing  accomplished  by  the  use  of  whole-thickness 
grafts. — I,  2  and  3.  At  the  time  of  admission,  twenty-two  months  after  the  accident 
(scalping,  by  hair  being  caught  in  rapidlj'  revolving  shaft) ,  the  granulations  were  exuberant 
and  oedematous  and  could  be  moved  from  side  to  side.  Photographs  taken  three  weeks 
after  admisson.  The  granulations  are  clean  and  ready  for  grafting.  The  narrow  zone  of 
cicatrization  seen  on  the  edges  shows  the  extent  of  healing  during  the  twenty-two  months 
which  have  elapsed  since  the  accident,  and  indicates  the  slowness  of  unassisted  healing  in 
these  cases.  4.  The  rubber  impregnated  mesh  holding  the  whole-thickness  grafts  in  posi- 
tion. By  this  means  the  grafts  may  be  absolutely  immobilized,  which  is  a  difficult  matter 
in  this  situation.      The  button-holes  in  the  graft  can  be  seen. 

injuries.  These  are  quite  unusual.  (2)  Those  which  occur  during 
the  progress  of  the  treatment,  erysipelas,  abscess,  necrosis  of  the  bone, 
etc.     (3)  Those  which  are  due  to  cicatricial  contracture.     These  con- 


123  4 

Fig.  307. — Complete  scalping  continued. —  i,  2  and  3.  Result  of  covering  the  denuded 
area  shown  in  Fig.  306  with  whole-thickness  grafts.  This  gives  a  much  more  stable  healing 
than  when  Ollier-Thiersch  grafts  are  used  in  these  cases.  There  is  also  less  tendency  to 
sub.sequent  contracture.  4.  The  patient  wearing  a  wig.  Photograph  taken  one  month 
after  leaving  the  hospital.  The  ultimate  result  in  this  case  has  been  satisfactory.  The 
patient  during  the  eleven  years  which  have  elapsed  since  grafting  has  been  able  to  continue 
her  occupation.  There  has  been  no  contracture.  Except  for  occasional  superficial 
ulcerations  between  the  grafts  no  compHcation  has  occurred  during  this  period. 

tractures  cause  hideous  deformities,  such  as  ectropion  of  the  upper 
eyelids.  Both  lids  are  pulled  upward  and  outward,  and  a  MongoHan 
expression  results.     Occasionally  an  eye  is  lost  from  infection. 


AS   APPLIED    TO    THE   VARIOUS    REGIONS 


347 


Treatment. — It  is  seldom  that  the  plastic  surgeon  sees  a  case  of 
scalping  immediately  after  the  accident,  it  being  usually  referred  to 
him  after  ordinary  methods  of  treatment  have  failed.  It  might  be 
said,  however,  that  there  is  no  authentic  record  of  a  case  of  complete 
scalping  in  which  the  replaced  scalp  survived. 


Fig.  308. — Complete  scalping  with  spontaneous  healing. — i  and  2.  Condition  five 
years  after  the  accident.  Multiple  ulcers  may  be  seen  scattered  over  the  thin  scar.  Note 
the  superficial  vessels  in  the  scar.  The  eyelids  are  drawn  upward  and  outward,  giving  a 
Mongolian  expression.  The  lids  could  be  closed  only  with  an  efTort.  The  entire  scar  is 
tightly  drawn  over  the  underlying  bone  and  the  slightest  injury  causes  an  ulcer.  3.  Two 
weeks  after  a  relaxation  incision  was  made  across  the  forehead  which  was  grafted  with  a 
single  long  Ollier-Thiersch  graft.  Note  the  relief  of  tension  and  the  improved  appear- 
ance of  the  ulcerated  area,  due  to  relaxation  of  the  scar. 

The  problem  is  to  combat  infection,  build  up  the  condition  of  the 
patient,  and  to  cover  the  area  with  skin.  There  has  been  a  good  deal  of 
dispute  as  to  the  best  time  to  graft,  whether  immediately  after  the 
accident,  or  after  granulations  have  formed.     My  own  preference  is  to 


Fig.  309. — Complete  scalping,  contitiued.  1.  Two  weeks  after  making  the  relaxation 
incision  and  grafting.  Note  the  ease  with  which  the  eyes  are  shut  and  the  position  of  the 
lids.  2  and  3.  Six  months  after  grafting.  Note  the  improved  condition  of  the  scar. 
The  Mongolian  appearance  has  disappeared  and  the  closure  of  the  lids  is  normal.  There 
is  still  some  sensation  of  tightness  over  the  vertex.  This  will  be  relieved  by  properly 
placed  relaxation  incision  with  grafting. 

wait  until  the  defect  is  covered  with  granulations,  inasmuch  as  the 

chance  of  success  is  greater  on  account  of  the  improved  blood  supply  and 

the  patient  is  usually  in  better  condition  to  stand  operative  procedures. 

If  immediate  grafting  is  decided  on,  Ollier-Thiersch  grafts  are  ordi- 


348 


PLASTIC    SURGERY 


narily  used  and  are  placed  directly  on  the  denuded  area.  Strips  of  the 
avulsed  scalp  (if  not  too  much  bruised)  can  be  used,  after  proper  cleans- 
ing, as  whole-thickness  grafts.  If  grafting  is  delayed,  we  endeavor  to 
hasten  the  growth  of  granulation  tissue  over  the  surface  of  the  defect. 
[f  any  portion  of  the  skull  is  denuded  of  periosteum,  this  area  should 
be  kept  moist  with  rubber  protective  until  granulations  form.  The 
periosteum  itself  should  not  be  allowed  to  dry  out,  as  the  bone  beneath 
may  become  necrotic.  If  the  bone  dies  the  dead  portion,  if  it  does  not 
exfoliate  must  be  scaled  off,  or  holes  must  be  bored  through  it  to  the 
diploe  with  a  fine  driU,  to  allow  granulations  to  form.     The  first  record 


Diploe 

Fig.  310. — Operation  for  hastening  the  growth  of  granulations  on  denuded  bone 
(Mayo).  I.  Drilling  through  the  bone  of  the  skull  to  the  diploe  to  allow  the  growth  of 
granulation  tissue.  2.  Granulation  tissue  appearing  through  the  perforations.  3. 
Transverse  section  showing  the  granulations  and  the  opening  into  the  diploe. 

of  this  procedure  is  that  of  Felix  Robertson,  who  performed  the  opera- 
tion in  1777  (Fig.  310). 

If  grafting  is  postponed  until  the  granulations  are  formed,  it  may 
be  either  done  partially  or  completely,  depending  on  the  size  of  the  area 
and  the  amount  of  material  available  at  one  operation. 

Ollier-Thiersch  grafts  are  used  by  most  operators.  In  some  cases 
Reverdin  grafts,  or  small  deep  grafts  have  been  preferred.  My 
preference  is  for  whole-thickness  grafts,  as  the  healing  in  the  end  is 
much  more  stable  than  with  the  other  types.  The  newly  formed  scalp 
is  never  as  resistant  as  the  original  skin,  and  it  is  needless  to  say  that 
there  is  never  much  hair  on  the  healed  surface,   even  when  whole- 


AS    APPLIED    TO    THE    VARIOUS    REGION'S 


349 


thickness  grafts  have  been  used.  Subsequently  as  a  result  of  any  slight 
injury  small  ulcers  may  occur  over  the  surface,  if  grafted  with  Ollier- 
Thiersch  grafts  or  Reverdin  grafts,  and  between  the  whole-thickness 
grafts.     These  ulcers  can  be  promptly  healed  with  small  deep  grafts. 

There  is  less  danger  of  contracture  after  healing  with  whole-thick- 
ness grafts  than  with  Ollier-Thiersch  or  Reverdin  grafts.  Occasionally 
a  case  of  complete  scalping  will  heal  spontaneously  after  many  months, 
but  the  result  is  generally  bad,  as  subsequent  ulceration  and  contrac- 
ture always  occur. 

Sensation  gradually  returns  from  the  periphery,  both  in  the  grafted 
cases  and  in  those  which  heal  spontaneously.  A  suitable  wig  should  be 
worn  after  healing  is  complete  and  the  appearance  is  surprisingly  good. 


A  B 

Fig.  311. — Operation  for  shifting  in  flaps  for  the  repair  of  a  scalp  defect  (Tilhnanns). 
A.  The  shaded  area  represents  the  wound.  The  flaps  i,  2,  3,  4,  are  indicated  by  the  dotted 
lines.  B.  The  flaps  shifted  in  and  sutured  to  each  other,  dividing  the  wound  into  four 
smaller  defects. 


Smaller  defects  may  either  be  grafted  or  closed  by  a  plastic 
operation  such  as  the  method  of  Tillmanns,  who  shifts  in  four  pedun- 
culated flaps  of  whole-thickness  skin  from  the  margins  and  sutures 
the  ends  together  across  the  wound,  dividing  it  into  four  smaller  areas. 
The  epithelium  will  then  close  over  these  areas  much  faster  than  over 
the  single  larger  one.  Or,  if  desirable,  the  smaller  areas  may  be 
grafted  (Fig.  311). 

Ulcers. — We  find  at  times  chronic  ulcers  of  the  scalp  of  considerable 
size,  due  to  tuberculosis,  syphilis  (broken  down  gummata),  a;-ray 
burns  and  carcinoma.  The  only  method  of  treatment  in  these  cases 
is  complete  excision,  and  then  closure  at  the  proper  time  by  grafting 
or  plastic  operation.  In  a  malignant  growth  the  glands  must  also 
be  excised. 


350 


PLASTIC    SURGERY 


Angiomata  (arterial,  venous,  and  cavernous)  of  the  scalp  are  quite 
common,  and  may  be  excised  or  treated  as  in  any  other  region. 


Fig.  312. —  Ulcer  of  the  scalp  following  the  excision  of  an  epithelioma  with  the  cautery. — 
I.  Before  grafting.  2.  After  grafting  with  small  deep  grafts.  This  patient  who  was  seventy- 
five  years  old  was  grafted  in  the  Out-patient  department  and  only  returned  to  the  hospital 
for  dressings.      No  recurrence  has  followed. 


12  ,34 

Pig.  313. — Rodent  ulcer,  in  front  of  the  ear.  Duration  several  years. — i.  The  ulcer 
had  been  treated  with  X-ray  and  radium  and  is  complicated  by  a  burn.  The  anterior 
portion  of  the  helix  and  front  of  the  ear  is  involved  as  well  as  the  skin.  2.  The  area 
was  excised  and  the  ear  shortened  after  the  excision  of  the  diseased  tissue.  In  order  to  avoid 
a  bald  patch  in  this  area  a  pedunculated  flap  of  scalp  was  turned  down  and  sutured  into  the 
defect,  and  the  rest  of  the  area  was  grafted.  3.  The  result  of  the  operation.  Note  the 
growth  of  hair  on  the  flap.  The  hair  has  been  brushed  back  to  show  the  grafted  area 
above.  4.  The  hair  brushed  down  to  cover  the  bald  spot.  This  is  a  useful  method  and 
flaps  of  hair-bearing  skin  may  be  shifted  in  to  fill  areas  which  would  be  conspicuous  without 
hair. 


Fibrous  Growths. — True  fibromata  on  the  scalp  are  rare.     Occasion- 
ally, however,  they  grow  to  a  large  size,  and  are  referred  to  the  plastic 


AS   APPLIED    TO    THE   VARIOUS    REGIONS 


351 


surgeon.  The  only  satisfactory  method  of  treatment  is  by  partial 
gradual  excision,  or  complete  excision  at  one  time,  the  defect  being 
closed  by  grafting,  or,  if  not  too  large,  by  plastic  operation. 

Keloids  are  found  quite  frequently  on  the  scalp,  especially  in  the 
negro  race.  They  occur  in  old  scars  due  to  operation,  or  to  local  infec- 
tion (furunculosis).  The  treatment  has  already  been  considered  in  the 
chapter  on  keloid. 

In  scalp  defects,  especially  of  the  forehead,  I  have  found  it  useful 
at  times  to  employ  pedunculatetl  flaps  from  distant  parts. 


Fig.  314. —  Necrosis  of  the  skull  following  infection,  i.  Exposure  and  necrosis  of  the 
parietal  bone  following  acute  streptococcus  infection.  Note  the  few  granulations  springing 
up.  Boring  holes  down  to  the  diploe  is  the  method  of  choice  in  treating  a  case  of  this  kind. 
2.  Necrosis  of  the  parietal  bone  (Luetic).  Note  the  multiple  openings  through  the  scalp, 
and  the  black  necrosed  bone.  Removal  or  sloughing  of  the  entire  necrosed  area  is  necessary 
before  healing  can  take  place. 


SC.^LP  DEFECTS  ASSOCIATED  WITH  BONE  NECROSIS 

The  plastic  surgeon  sees  a  number  of  cases  in  which  the  unprotected 
bone  is  necrosed.  This  condition  may  result  from  trauma,  burns 
(thermic,  electric,  or  ic-ray),  from  syphilis,  tuberculosis,  or  malignant 
disease.  Extensive  areas  of  bone  may  be  lost  in  this  way.  In  those 
instances  in  which  only  the  outer  table  is  involved,  the  area  may  be 
covered  with  adjacent  skin  by  plastic  closure;  a  pedunculated  flap  from 
a  distant  part  may  be  used,  or  skin  grafting  may  be  employed.  In 
those  cases  in  which  it  is  necessary  to  remove  both  tables  of  bone  (for 
malignant   disease,    or   where   necrosis   has    already   occurred),    some 


352 


PLASTIC    SURGERY 


method  of  filling  the  bone  defect  must  be  considered  in  addition  to  the 
closure  of  the  skin.     The  best  procedure  for  this  will  be  considered  below. 


SKULL 

The  plastic  surgeon  is  often  consulted  as  to  the  best  method  of 
closing  a  skull  defect  and  correcting  the  deformity.  A  wonderful 
opportunity  has  been  presented  in  the  war  wounds  of  the  skull  to  deter- 
mine the  most  rational  and  safest  methods. 


Fig.  315. — Sequestrum  of  the  outer  table  of  the  skull,  following  a  burn.  (Surg.  No. 
30989). — The  burn  occurred  eleven  months  before  admission.  The  sequestrum  was  re- 
moved in  one  piece  and  the  defect  was  grafted  with  small  deep  grafts.  (This  case  was  not 
under  my  personal  care.) 

In  cases  of  cranial  defect  no  reparative  operation  should  be  under- 
taken until  the  heahng  of  the  original  wound  is  complete,  and  all 
chance  of  infection  (which  may  be  started  by  cutting  through  the 
recently  healed  scar)  can  be  eliminated. 

Asepsis  should  be  maintained  most  rigorously,  as  post-operative 
infection  is  disastrous. 

Several  methods  of  closing  skull  defects  may  be  mentioned. 

(i)  With  Periosteal,  Osteo-periosteal,  or  Cutaneous-osteoperios- 
teal  Flaps.^ — Many  ingenious  operations  have  been  devised  for  closing 


AS    APPLIED    TO    THE    VARIOUS    REGIONS 


353 


defects  by  the  use  of  pedunculated  flaps  (simple  or  compound)  from 
adjacent  tissue,  but  I  shall  not  consider  them  at  this  time,  inasmuch 
as  war  experience  has  demonstrated  the  success  to  be  obtained  from 
the  less  complicated  methods  of  direct  transplantation. 

(2)  Decalcified  bone;  isocranial  bone;  the  bones  of  animals,  and 
even  cowhorn  have  been  used  with  more  or  less  success. 

(3)  Prosthetic  Method. — Very  thin  plates  of  gold,  siWer,  aluminium, 
platinum,  celluloid  and  ivory  have  been  used,  and  the  simplicity  of  the 
measure  makes  it  attractive.  Nevertheless  the  same  objection  exists 
here  as  elsewhere  to  burying  non-absorbable  inorganic  substances, 
because  if  any  infection  should  occur,   the  plate  must  be  removed. 


Fig.  316. — Luetic  osteomyelitis  of  the  skuU.  (Surg.  No.  37639).  A.  The  outer  table 
of  bone  has  been  removed  over  the  area  between  the  brows  and  the  vertex  of  the  skull. 
The  defect  has  been  grafted.  Note  the  peculiar  slope  of  the  forehead.  B.  Front  view  with 
eyes  closed.  Note  the  ectropion  of  the  upper  lid  following  scar  contracture.  (This  case 
was  not  under  my  personal  care.) 

Good  results  have  been  reported  by  the  use  of  this  method,  but  I  prefer 
the  bone  or  cartilage  transplants. 

When  plates  of  any  sort  are  used  it  is  best  to  perforate  them  with  a 
number  of  small  holes.  In  this  way  they  are  made  lighter,  the  blood  or 
serum  can  escape  through  the  holes,  and  subsequently  little  plugs  of 
tissue  grow^  into  them.  The  method  of  preparation  before  inserting 
the  plate  is  much  the  same  as  will  be  described  for  bone  or  cartilage 
grafts.  Most  authors  agree  that  the  plate  should  be  made  to  fit  the 
defect  exactly,  and  be  held  in  position  by  several  arms  which  rest  on  the 
surrounding  skull.  These  arms  should  not  be  placed  on  a  cranial 
suture.  When  celluloid  or  ivory  is  used,  it  must  rest  on  the  bone 
surrounding  the  defect  or  on  a  ledge  cut  to  receive  it. 

23 


354 


PLASTIC    SURGERY 


(4)  Fascia  and  Skin. — Free  fascia  lata  transplants  have  been  used 
with  success  for  closing  skull  defects  (as  well  as  for  dural  defects)  and 
good  results  are  reported.  It  maybe  sutured  to  the  pericranium,  or  the 
edges  of  the  flap  may  be  tucked  between  the  dura  and  the  bone.  The 
result  is  a  strong,  resistant  membrane. 


Fig.  317. — Hernia  of  the  brain  following  a  decompression  for  the  relief  of  an  abscess  of 
the  temporal  lobe.  (Surg.  No.  28923). — i.  Before  grafting  with  small  deep  grafts.  2. 
One  week  after  grafting.  .The  skin  rapidly  covered  the  tumor  and  simplified  the  care  of 
this  patient. 

Experimentally  I  have  found  that  the  fascia  when  applied  in  either 
of  the  ways  described  above,  eventually  blends  with  the  surrounding 
tissues,  and  forms  a  taut,  non-stretching  membrane. 

Skin. — Begouin  has  described  an  ingenious  method  of  utilizing 
pedunculated  flaps  of  the  scalp  for  closing  a  cranial  defect,  which  is 


Pig.  318. — Cranioplasty  for  a  small  defect  by  the  use  of  scalp  flaps  {Begouin). — The  arrows 
show  the  flaps  of  scalp  split  off  on  the  under  surface  and  turned  into  the  defect. 

appropriate  for  small  defects  when  cartilage  cannot  be  utiHzed.  This 
method  is  well  shown  in  the  diagram  and  will  require  no  further  explana- 
tion. It  is  important  after  closure  by  this  method  to  exert  even  pres- 
sure to  obhterate  dead  spaces  (Fig.  318). 


AS  APPLIED  TO  THE  VARIOUS  REGIONS 


355 


(5)  Cartilaginous  Grafts. — Autografts  from  the  costal  cartilages 
are  preferable,  but  good  results  have  been  reported  from  the  use  of 
isografts. 

The  technic  in  brief  is  as  follows:  The  incision  best  suited  to  the 
case  is  made  down  to  the  subaponeurotic  layer  and  the  defect  is  exposed. 
The  island  of  scar  is  excised,  but  care  should  be  taken  during  the  dis- 
section not  to  perforate  or  disturb  the  thin  fibrous  tissue  plug  which 
fills  the  dura  defect.  Cut  through  the  pericranium  around  the  edge  of 
the  bone  defect  and  clear  the  edges  of  all  spicules  of  bone,  so  that  an 
instrument  can  be  passed  between  the  dura  and  bone.  Then  remove 
the  grafts  from  the  costal  cartilage  as  previously  described. 

In  order  to  hold  the  grafts  in  place  a  network  of  fine  catgut  is  made 
(in  both  directions  if  necessary),  passing  through  the  pericranium  on 


Ed(^e  of  Pericranium 

/Fibrous  Tissue 


Fig.  319. — Method  of  repairing  cranial  defects  with  cartilage  grafts  {Woodroffe). — 
I.  Diagrammatic  drawing  showing  the  clearing  of  the  margin  of  the  defect,  including  the 
separation  of  the  dura  on  the  deep  surface.  2.  The  cartilaginous  grafts  are  inserted 
between  the  dura  and  the  catgut  network. 

both  sides,  after  Villandre's  method;  under  this  the  grafts  are  slipped. 
The  perichondria!  side  should  be  next  to  the  dura;  the  grafts  should 
overlap  and  may  even  be  placed  in  a  double  layer.  The  cartilage  may 
also  be  placed  across  the  defect  and  rest  on  a  ledge  of  bone,  as  described 
in  the  next  section  (bone  grafts).  It  may  be  secured  with  catgut,  or 
a  very  close  fit  may  be  made.  In  the  frontal  and  temporal  regions  care 
should  be  taken  to  match  the  contour  of  the  normal  side  as  closely  as 
possible  (Fig.  319). 

Hemostasis  is  essential.  The  healing  should  be  as  perfect  as  pos- 
sible, and  every  care  should  be  taken  in  suturing  the  flap.  A  twisted 
silkworm  gut,  or  horsehair  drain  is  desirable  for  48  hours. 

Many  good  results  have  been  reported  following  the  use  of  cartilage 
grafts  by  Morestin,  who  first  introduced  the  method,  by  Cosset,  Villan- 
dre,  Woodroffe,  and  others. 

(6)  Bone  Grafts. — The  defect  is  exposed  by  any  incision  desired, 
which  should  extend  through  the  scalp  only.     The  opening  is  prepared 


356  PLASTIC    SURGERY 

in  a  manner  similar  to  that  already  described  under  cartilage  grafts. 
The  pericranium  is  raised  for  about  2.5  cm.  (i  inch)  around  the  opening, 
and  a  strip  of  the  outer  table  of  bone  about  1.25  cm.  (3^^  inch)  wide  is 
removed  all  around  the  defect,  the  object  being  to  make  a  ledge  on  which 
the  bone  graft  is  to  rest. 

The  bone  may  be  obtained  from  the  outer  table  of  the  skull  adjacent 
to  the  defect,  from  the  scapula,  the  great  trochanter,  or  most  commonly 
from  the  tibia  or  ribs.  My  preference  is  for  the  ribs.  Autografts  are 
preferable,  although  isograf ts  may  be  used.  The  bone  (with  its  peri- 
osteum, if  possible),  after  being  shaped  to  fit  snugly,  is  placed  on  the 
ledge  previously  prepared.  The  periosteum,  if  present,  is  sutured  to 
the  pericranium,  or  a  catgut  network  may  be  used.  The  defect  should 
be  covered  completely.  A  single  graft  is  preferable,  but  multiple 
grafts  are  very  satisfactory,  and  many  good  results  have  been  reported. 
The  skin  is  carefully  closed  with  horsehair.  A  silkworm  gut  or  twisted 
horsehair  drain  may  be  desirable. 

Experimentally  I  have  found  that  bone  will  soon  fill  the  spaces 
between,  if  the  strips  of  rib  not  touching  each  other,  are  laid  across  an 
opening  in  the  skull.  Moreover,  if  bits  of  bone  are  scattered  on  the 
soft  parts  in  the  defect,  a  solid  closure  will  result,  the  under  surface  of 
which  is  smooth. 

Cartilage  or  bone  transplants  are  unquestionably  best  for  filling 
cranial  defects;  some  operators  prefer  the  former,  some  the  latter. 
My  own  preference  is  for  cartilage;  it  is  easy  to  obtain  and  is  much 
more  plastic. 

BIBLIOGRAPHY 

Arana,  G.  B.     "Revista  de  la  Asoc.  Med."     Argentina,  Sept.,  191 7,  225. 

Begouin.     "Gaz.  hedb.  d.  sc.  med."     Bordeaux,  xxxviii,  191 7,  6. 

Besson,  a.     "Jour.  d.  sc.  med.  de  Lille,"  ii,  Dec.  15  and  22,  1906,  pp.  545,  569. 

Capitan  &  Delair.     "Bull  de  I'Academie  de  Med."     Paris,  March  14,  1916. 
Gushing,  H.     "Keen's  Surgery,"  iii,  36. 

Duv.\L,  P.     Paris  Letter.     "Jour.  Amer.  Med.  Assn.,"  May  6,  1916,  1477. 

Eddovves,  a.     "Med.  Press  &  Circul."     London,  April  23,  1913,  440. 

Funke.     "Zent.  f.  Chir.,"  Nr.  17,  1915,  257. 

Gar,  G.  L.     "Vrach.  Gaz."     St.  Petersburg,  xix,  191 2,  367. 

Cosset,  M.  A.     "Bull,  et  mem.  de  la  Soc.  de  Chir.  de  Par.,"  May  24,  1916,  1599. 

Jeger,  E.     "Beitr.  z.  klin.  Chir.,"  xcvii,  1915,  418. 
Jones,  B.  L.     "Anns.  Surg.,"  Sept.,  1917,  160. 


AS    APPLIED    TO    THE   VARIOUS    REGIONS  357 

Le  Fl'r,  R.     "Paris  Chir.."  1916,  viii,  505. 

"Presse  Med."     Paris,  March  2,  1918,  xxvi,  153. 
Leotta.     "Deutsche  Zeitschr.  f.  Chir.,"  Bd.  103,  Heft,  i  und  2,  1910. 
Lewis,  Deax.     "Anns.  Surg.,"  Feb.,  1918,  149. 
LoFBERG,  O.     "Xordische  med.  Archiv."     Stockholm,  xlvi,  Surg.  Sec.  3. 

Mariau.     "Paris  Med.,"  April  i,  1916. 

Mason  &  Lester.     "Anns.  Surg.,"  Nov.,  1909,  815. 

Mauclaire.     "Paris  Med.,"  Oct.  7,  1916. 

Mayo,  C.  H.     "Anns.  Surg.,"  Sept.,  1914,  371. 

Mitchell,  A.  B.     "Brit.  Jour.  Surg.,"  July,  191 7,  48. 

Morestix,  H.     "Bull,  et  mem.  de  la  Soc.  de  Chir.  de  Par.,"  Oct.  27,  1915,  1994. 

"Ibid.,"  Feb.  9,  1916,  333. 

"Ibid.,"  May  24,  1916,  1593. 
Morison,  a.  E.     "Brit.  Jour.  Surg.,"  Jan.,  191 7,  454. 

Rexard,  J.     "Theses  de  doct."     Lyon,  1913. 

Robertson,  Feldc.     "Phila.  Med.  &  Physical  Jour.,"  1806,  pp.  27-30. 

Ruppert.     "Wiener  klin.  Wchnschr.,"  Nr.  2,  1904. 

SiCARD,  M.     "Bull,  et  mem.  de  la  Soc.  de  Chir.  de  Par.,"  Mar.  24,  1916,  1610. 

SiCARD  &  Dambrix.     "Presse  Med.,"  1917,  60. 

SiCARD,  Dambrix  &  Riger.     "Presse  Med."     Paris,  191 7,  577. 

Smirxoff.     "Dissertation."     St.  Petersburg,  1913. 

Stoxe,  J.  S.     Bryant  &  Buck:  "American  Practice  of  Surgery,"  iv,  628. 

TiLLMANNS.     "Text-book  of  Surgery."     Tilton,  1897,  ii,  p.  13. 

ViLLANDRE.     "Jour.  dc  Med.  et  Chir.,"  Aug.  10,  1916. 
"Presse  iled.,"  Sept.  11,  1916. 

WooDROFFE,  H.  L.  W.     "Brit.  Jour.  Surg.,"  July,  191 7,  42. 


CHAPTER  XVII 
SURGERY  OF  THE  EYELIDS  (BLEPHAROPLASTY) 

Quite  a  number  of  patients  needing  surgical  care  of  the  eyelids  have 
been  referred  to  me  by  ophthalmic  surgeons;  others  have  come  under  my 
care  in  connection  with  the  correction  of  more  extensive  deformities 
of  the  face. 

Before  attempting  this  work  one  should  become  familiar  with  the 
principles  involved  and  with  the  methods  of  procedure.  Unfortunately, 
even  with  proper  treatment,  the  results  may  be  unsatisfactory. 


Pig.  320. — Pigmented  mole  of  the  eyelid. — i.  Note  the  size  and  shape  of  the  mulberry- 
like mole  on  the  lower  lid.  The  problem  was  to  remove  the  mole  with  a  sufficient  margin 
and  at  the  same  time  to  close  the  defect  without  distortion  of  the  eyelid.  2.  Note  the  scar 
left  six  months  after  excision.  The  defect  after  excision  was  rectangular  in  shape.  Inci- 
sions were  then  made  from  the  upper  and  lower  extremities  of  the  defect  outward  and  in- 
ward, parallel  to  the  natural  folds  of  the  skin,  and  the  flaps  thus  formed  were  shifted  in  and 
sutured  in  the  midline.  The  shape  of  the  sutured  area  being  that  of  an  H  on  its  side. 
There  is  no  constriction  of  the  lower  lid,  and  the  scar  can  scarcely  be  noticed. 

The  object  of  the  operator  is  to  replace  the  destroyed  tissues  with 
normal  skin  in  the  way  best  suited  to  the  individual  case.  It  is  always 
desirable  to  overcorrect  in  all  operations  on  the  lids,  because  we  have 
to  allow  for  subsequent  shrinkage. 

The  type  of  operative  procedure  depends  on  the  depth  of  destruction. 
For  instance,  if  the  tarsus  and  conjunctiva  have  been  destroyed  in  addi- 
tion to  the  skin,  in  order  to  reconstruct  an  eyelid  some  form  of  epithelial 
lined  flap  must  be  provided. 

If  the  skin  surrounding  these  deformities  were  always  normal,  the 
operations  shown  in  the  diagrams  would  be  comparatively  easy. 
As  a  matter  of  fact,  in  the  great  majority  of  the  cases  which  have  come 
under  my  care,  either  the  tissue  surrounding  the  defect  consisted  of  scar, 

358 


SURGERY    OF    THE    EYELIDS 


359 


Pig.  321. — Hotz-Anagnostakis  operation  for  entropion. — Excision  of  the  fibers  of  the 
orbicularis  muscle'(^w.)  covering  the  tarsus  (ta.).  With  forceps  the  fibers  are  grasped  at  the 
left  angle  !of  the  incision;  a  small  pair  of  curved  scissors  is  applied  close  to  the  tarsus, 
and  with  short  cuts  the  muscle  is  separated  along  the  entire  length  of  the  lid  (Meller).  -x 


Fig.  322. — Hotz-Anagnostakis  operation,  (onlinued. — Withthe  knife  applied  flat  against 
the  convex  anterior  surface  of  the  thickened  tarsus  {ta.),  thin  slices  are  cut.  The  upper 
border  of  the  tarsus  and  the  margin  of  the  lid  are  not  disturbed  (Meller). 


360 


PLASTIC    SURGERY 


or  the  skin  of  the  entire  face  was  infiltrated  with  scar  tissue.     In  such 
cases  it  becomes  necessary  to  utiUze  the  scar  tissue  wherever  possible, 


t-a. 


Fig.  323. — Hotz-Anagnostakis  operation,  continued. — Two  of  the  sutures  are  applied. 
They  pass  from  above  through  the  skin  (m.)  ;  then  through  the  upper  border  of  the  tarsus 
(ia.),  in  which  they  are  firmly  fastened;  and  lastly  through  the  lower  margin  of  the  skin  (Z.) 
above  the  cilia.  Corresponding  to  the  convex  form  of  the  upper  tarsal  border,  the  tarsal 
point  of  insertion  of  the  outer  and  inner  suture  is  nearer  the  lower  margin  of  the  wound 
than  that  of  the  middle  suture  (Meller). 

and  much  can  be  accomplished  if  the  scar  is  movable  and  can  be  shifted. 
However,  normal  tissue  should  be  used  if  the  defect  is 
to  be  permanently  corrected. 


RECENT  WOUNDS 

Fig.    324  — 

The  tarsus  has  If  by  chaucc  a  reccut  wound  of  the  eyelids  should  be  re- 
ward during  the  ferred  to  the  plastic  surgeon,  the  parts  should  be  properly 
ciosmg    of    the  cleansed  and  then  brought  together,  care  being  taken  that 

skm-wound.  ...  007  o 

The  eyelashes  are  conjunctiva  is  sutured  to  conjunctiva,  skin  to  skin,  etc. 
and^'sHghtiy^up-  Much  can  be  accomplished,  even  when  the  tissues  are 
ward  (Meller).      badly  lacerated,  by  a  few  sutures  judiciously  placed. 

Preliminary  Preparation. — The  eye  should  be  irrigated  every  three 
hours  with  warm  salt  solution  on  the  day  before  operation,  in  the  intervals 


SURGERY    OF    THE    EYELIDS 


361 


Fig.  325.  Fig.  326. 

Pig.  325. — Snellen  operation,  for  entropion  (Meller). — A  wedge-shaped  piece  (e.)  of 
the  tarsus  is  excised.      Sutures  in  place,     s.,   skin;   w.,   muscle;  ta.,   tarsus. 

Fig.  326. — Snellen  operation,  continued. — Vertical  section  through  the  ixpper  lid,  show- 
ing the  cuneus-shaped  excision  (e.)  of  the  tarsus  {la.),  with  the  suture  (5.)  (Meller). 


ta 


Fig.  327. — Panas'  operation  for  entropion  {Meller). 

Fig.  327,  I. — After  cutting  through  the  skin  {s.)  and  muscle  (w.),  the  tarsus  (ta.)  and 
conjunctiva  are  incised,  over  an  ivory  plate  placed  between  lid  and  bulb,  along  the  entire 
length  of  the  lid.  The  central  suture  has  already  been  introduced.  Above  it  is  fastened 
to  the  tarsus  near  the  edge  of  the  tarsal  wound.  Both  ends  of  the  suture  pass  down- 
ward between  tarsus  and  muscle  and  emerge  in  the  intermarginal  border  behind  the  cilia. 
Over  one  end  of  the  suture  a  glass  bead  is  drawn. 

Fig.  327,  2. — Sagittal  section  through  the  upper  lid  after  completion  of  the  operation. 
The  margin  of  the  lid,  now  placed  vertically  to  the  plane  of  the  lid,  is  so  adjusted  to  the 
tarsus  (ta.)  that  no  part  of  it  projects  into  the  palpebral  fissure;  in  fact,  only  a  small  por- 
tion of  the  wound-surface  (the  cut  edge  (c.)  of  the  tarsus)  remains  exposed  {Meller). 


36: 


PLASTIC    SURGERY 


continuous  wet  compresses  should  be  applied.  These  procedures  should 
be  continued  until  the  time  of  operation,  when  the  surrounding  skin  is 
washed  thoroughly  with  ether  or  benzin  and  then  painted  with  one-third 
strength  tincture  of  iodin  to  the  mucocutaneous  junction.  Orechkin 
is  said  to  use  two-thirds  strength  tincture  of  iodin  inside  the  eye  as  well 
as  on  the  skin.  This  seems  to  be  a  very  heroic  procedure,  inasmuch  as 
all  unnecessary  irritation  of  the  conjunctiva  should  be  avoided  when 
operating  on  the  lids. 

Anesthesia. — Many   of   the  minor   procedures   should  be   carried 
out  under  local  anesthesia.     If  an  extensive  operation  with  complicated 


Fig.  328. — Panas'  operation  for  entropion  Fig.  329. — Graefe's  operation  for  entro- 

(Beard).  pion  (Beard). 

Fig.  328. — A  vertical  incision  about  i.  cm.  (^^  inch)  long  is  made  through  the  skin  and 
muscle  below  each  canthus.  These  are  joined  by  a  horizontal  incision  through  the  skin 
only,  and  the  flap  is  dissected  up  to  the  lid  margin.  A  strip  of  the  premarginal  portion  of 
the  lorbicularis  muscle  is  excised.  The  desired  amount  of  skin  is  removed  from  the  free 
end  of  the  flap,  and  the  wound  is  closed. 

Fig.  329. — An  incision  is  made  through  the  skin  and  muscle  the  length  of  the  lid,  0.3  cm. 
(3^  inch)  below  and  parallel  to  it.  A  triangle  of  skin  of  the  desired  size  is  removed. 
The  skin  and  muscle  along  the  margin  is  raised  and  the  muscle  is  removed.  The  dotted 
triangle  indicates  the  outline  of  the  incision  for  the  removal  of  the  tarsus,  if  necessary.  The 
skin  flaps  are  undermined  and  the  wound  is  sutured. 


flaps  is  planned,  it  is  advisable  to  use  a  general  anesthetic,  as  the  in- 
filtration would  distort  the  tissues  and  make  the  proper  flap  outlines 
difiicult  to  calculate. 

Suture  Material. — In  operating  on  the  lids  I  prefer  horsehair  for 
all  the  skin  sutures  and  very  fine  silk  (oiled  or  vaselined)  for  the  lid 
margins  or  the  conjunctiva. 

Dressings.^ — A  drop  of  sterile  castor  oil  instilled  into  the  eye  before 
and  after  operating,  is  very  efficacious  in  diminishing  the  amount  of 
the  resulting  irritation. 


SURGERY  OF  THE  EYELIDS 


363 


Before  the  dressing  is  placed  care  should  be  taken  that  no  stitch 
end  is  left  between  the  lids;  the  neglect  of  this  precaution  has  often 
caused  much  needless  discomfort. 


Fig.  330. — Bilateral  contracture  following  a  burn,  with  partial  ectropion  of  both  lids, 
preventing  closure.  Duration  seven  years. — i.  The  lids  cannot  be  closed  more  than  is 
shown  in  the  photograph.  When  asleep  the  eyeballs  are  rolled  upward.  2.  Twenty 
months  after  the  relief  of  the  contracture  and  transplantation  of  whole-thickness  grafts 
into  the  upper  and  lower  lids  of  both  eyes.  Note  the  perfect  closure.  The  alae  have  also 
been  repaired. 


Pig.  331. — Ectropion  of  both  lids  of  the  left  eye  following  a  burn  twelve  years  before  ad- 
mission. I.  Note  the  opacity  of  the  cornea,  and  the  extensive  scarring  of  the  forehead  and 
cheek.  2.  Three  weeks  after  releasing  the  upper  lid  and  transplanting  a  whole-thickness 
graft  from  the  arm.  3.  Three  months  after  transplantation  to  the  upper  lid,  and  one 
month  after  the  transplantation  of  a  whole-thickness  graft  into  the  lower  lid.  The  condi- 
tion of  the  left  eye  improved  so  rapidly  after  the  formation  of  the  lids  that  light  and  dark- 
ness could  be  distinguished,  and  it  was  decided  not  to  enucleate  the  eye. 

A  smear  of  yellow  oxid  of  mercury  ointment  (gr.  }  •>  to  the  dram  of 
vaselin)    along   the  lids  is  used  before  the  dressing  is  applied.     Over 


364 


PLASTIC    SURGERY 


this  are  placed  several  layers  of  gauze  wet  with  normal  salt  solution, 
and  then  wet  cotton,  all  being  secured  with  a  bandage.  The  dressing 
may  or  may  not  be  kept  wet,  as  seems  desirable.  Both  eyes  should 
be  included  in  the  dressing  for  the  first  day  at  least. 


Fig.  332. — Unilateral  ectropion  of  both  eyelids  following  a  burn.  Duration  two  and 
one-half  years. — i.  Note  the  involvement  of  the  left  cheek,  side  of  the  face  and  the  ectro- 
pion of  both  eyelids.  2  and  3.  Ten  days  after  release  of  the  lids  and  implantation  of 
whole-thickness  grafts  above  and  below. 

ENTROPION  (INVERSION  OF  THE  EYELID) 

The  majority  of  these  cases  which  come  under  the  care  of  the  plastic 
surgeon  are  of  the  cicatricial  variety  following  severe  burns  and  are 


Fig.  333. — Unilateral  ectropion  of  both  eyelids,  continued. — i  and  2.  Taken  two 
months  after  grafting.  In  the  meantime  one  or  two  operations  were  done  to  lower  the 
left  side  of  the  mouth  and  to  reconstruct  the  left  ala.  3.  Condition  two  years  after  opera- 
tion. The  eyelids  can  be  closed  but  further  improvement  can  be  made.  The  presence  of 
scar  prevented  the  use  of  a  flap  of  neighboring  skin  in  this  case.  However  a  flap  from  the 
neck  might  have  been  used. 

associated  with  other  contractures.  The  tarsus  is  warped  and  thickened 
and  the  conjunctiva  is  atrophied.  This  condition  is  much  less  common 
than  ectropion. 

Numerous  operations  have  been  described  for  the  relief  of  this 


SURGERY    OF    THE    EYELIDS 


36: 


condition;  in  my  experience  the  deformity  is  difficult  to  correct  and  no 
one  method  can  be  depended  upon. 

The  appended  diagrams  of  the  Hotz-Anagnostakis,  Snellen,  Panas, 
and  Graefe's  procedures  are  self-explanatory  (Figs.  321-329). 

ECTROPION  (EVERSIOX  OF  THE  EYELID) 

Cicatricial  ectropion  is  due  to  contracture  of  the  skin  following 
burns,  or  other  forms  of  ulceration. 

Ectropion  may  be  treated:  (i)  By  skin  grafting;  (2)  hy  sliding  flaps 
(French  method);  (3)  by  pedunculated  flaps  from  adjacent  tissue 
(Indian  method);  (4)  by  pedunculated  flaps  from  distant  parts  (Italian 
method). 

I.  The  Use  of  Whole -thickness  Skin  Grafts  (the  original  operation 
of  Wolfe). 


Fig.  334. — Dieffenbach's  operation  for  ectropion  (Beard). — ^i.  The  dark  lines  indicate 
the  incisions.  2.  After  removal  of  the  scar  the  lateral  flaps  are  undercut,  shifted  inward 
and  sutured. 

The  scar  tissue  on  either  the  upper  or  lower  eyelids  is  excised  as 
completely  as  possible  and  the  lid  is  mobilized.  The  palpebral  margins 
are  held  together  with  several  sutures  or,  better  still,  one  is  drawn  over 
the  other  and  secured  with  sutures  and  a  graft  of  whole-thickness 
skin  is  titted  into  the  defect  and  secured  with  interrupted  sutures. 
Immobilization  is  important  for  a  few  days  at  least. 

The  skin  is  best  obtained  from  the  inner  side  of  the  upper  arm  where 
it  is  hairless  and  thin,  or  from  the  prepuce.  I  have  had  some  excellent 
results  with  this  method. 

The  use  of  Olher-Thiersch  grafts,  or  small  deep  grafts,  is  not  to 
be  advised  in  these  cases,  as  the  contracture  that  usually  follows  will 
cause  at  least  a  partial  recurrence. 

2 .  By  Sliding  Flaps  : 

Operation  of  Dieffenbach. — Three  straight  incisions  are  made 
around  the  adjacent  scar  in  the  form  of  a  triangle,  with  its  base  near 


366 


PLASTIC    SURGERY 


and  parallel  to  the  margin  of  the  lid.  This  area  is  excised,  and  two 
slightly  curved  incisions  are  then  made  from  the  corners  of  the  base 
of  the  triangle,  after  which  the  skin  is  undermined.  The  skin  on  the 
upper  side  of  the  entire  incision  is  dissected  up,  the  lid  is  placed  in  a 
normal  position,  and  the  edges  are  sutured,  forming  the  letter  T 
(Fig.  334). 

This  operation  can  be  used  only  for  small  lesions  on  the  lower  lid. 


Fig.  335. — Graefe's  operation  for  cicatricial  ectropion  (Beard). — a.  The  dark  lines 
indicate  the  incisions  splitting  the  lid  for  its  entire  length  into  two  leaves,  b.  The  inner 
leaf  of  tarsus  and  conjunctiva  is  turned  upward.  The  dotted  lines  indicate  the  portions  of 
the  outer  leaf  of  skin  and  muscle  which  are  removed,  c.  The  outer  leaf  is  shifted  upward 
to  cover  the  inner,  and  held  in  an  over-corrected  position  by  sutures  which  are  secured  to 
the  forehead. 


Operation  of  von  Graefe.— An  incision  is  made  along  the  border 
of  the  lid  from  the  inner  to  the  outer  canthus.  From  each  end  of  this 
incision  a  perpendicular  cut  of  the  desired  length  is  made  and  the 
flap  of  skin  is  separated  from  the  tarsus.  The  ectropion  is  corrected 
and  the  upper  edge  of  the  flap  is  trimmed  to  fit  the  tarsal  border.  From 
both  corners  of  the  flap  small  pieces  are  excised,  so  that  when  it  is 


SURGERY  OF  THE  EYELIDS 


367 


sutured,  the  skin  will  be  drawn  more  tightly  transversely.  The  sutures 
on  the  tarsal  border  are  left  long  and  are  fastened  to  the  forehead 
with  adhesive  plaster  or  collodion  and  gauze.  In  this  way  overcor- 
rection is  obtained  until  the  healing  is  well  started  (Fig.  335). 

This  operation  can  be  used  for  extensive  ectropion  of  the  lower  lid. 

Operation  of  Wharton  Jones. —  From  a  point  near  each  commissure 
two  converging  incisions  are  made  to  include  the  scar  and  meet  beyond 
in  the  shape  of  the  letter  V.  The  triangular  flap  is  dissected  up  to  the 
root  of  the  cilia  and  the  surrounding  skin  is  undermined.  The  lid  is 
then  pushed  up  and  overcorrected  and  the  edges  are  sutured  to  form 
a  Y  (Fig.  336). 


Fig.  336. — Wharton  Jones'  operation  for  ectropion  (Beard). — i.  A  V-shaped  incision  is 
made;  the  eyelid  is  released  by  undercutting  the  flap;  the  surrounding  skin  is  undermined. 
2.    The  skin  edges  are  sutured  in  the  shape  of  a  Y. 


This  very  useful  operation  is  designed  for  either  lid,  but  in  my 
hands  has  not  been  satisfactory  on  the  upper.  The  same  procedure  is 
used  for  ectropion  of  the  lip. 

In  severe  cases  of  long  standing,  in  addition  to  the  operations  de- 
scribed for  cicatricial  ectropion,  it  is  often  necessary  to  shorten  the  free 
border  of  the  lid  in  order  to  remove  the  excess  tissue.  This  may  be 
done  by  the  methods  used  for  atonic  ectropion,  and  can  be  readily 
followed  on  the  diagrams  of  the  operations  of  Adams,  von  Amnion,  and 
Kuhnt  (Figs.  337-339)- 

The  operations  just  mentioned  are  for  the  relief  of  ectropion  alone 
and  cannot  be  used  for  the  formation  of  a  new  eyelid. 


368 


PLASTIC    SIJRGERY 


The  Flap-sliding  Operation  of  Dieffenbach. — In  excising  the 
defective  tissue  on  the  lower  lid  a  triangular  gap  is  made,  with  its  base 
upward.  Care  should  be  taken  to  preserve  all  healthy  conjunctiva. 
A  horizontal  incision  is  made  outward  from  the  angle  of  the  gap  close 


Fig.  337. — Adams'  operation  for  atonic  ectropion  (Beard). 
A  wedge,  including  skin,  tarsus  and  conjunctiva  is  excised  from  the  center  of  the  lid,  and 
the  edges  are-sutured.      The  central  scar  is  undesirable. 

to  the  canthus.  This  should  be  long  enough  to  make  a  flap  sufficiently 
wide  to  fill  the  opening.  A  second  incision  is  made  from  the  outer  end 
of  the  horizontal  cut  parallel  to  and  of  the  same  length  as  the  outer 


Fig.  338. — Von  Amon's  modification  of  Adams'  operation  for  ectropion  (Beard). 
A  wedge,  including  skin,  tarsus  and  conjunctiva  is  excised  from  the  outer  canthus  and  the 
edges  are  sutured. 

border  of  the  triangle.  The  flap  thus  made  is  dissected  up  and  slid 
inward  to  fill  the  triangular  defect  and  sutured  into  place.  By  under- 
cutting the  surrounding  skin  a  considerable  portion  of  the  defect  left 
by  raising  the  flap  can  be  sutured.     The  part  that  cannot  be  closed 


SURGERY    OF    THE    EYELIDS 


369 


I  2 

Fig.  339. — Kuhnt's  operation  for  atonic  ectropion  (Beard). — i  and  2.  A  triangle 
of  tarsus  with  its  overlying  conjunctiva  is  excised  without  including  the  skin.  The  edges 
are  sutured  on  the  inside.  There  will  be  a  redundant  fold  of  skin  on  the  surface  which  may- 
be removed  after  shrinkage  has  ceased. 


I  2 

Pig.  340. — -A  combination  of  Kuhnt's  and  Dieffenbach's  operations  for  ectropion  of  the 
lower  lid  (Beard,  in  Wood). — i.  A  wedge  of  conjunctiva  and  tarsus  removed  from  the 
center  of  the  lid.  Also  a  triangular  area  of  skin  removed  from  beyond  the  outer  angle, 
as  shown  in  the  diagram.  2.  The  tarsal  wound  is  closed,  and  the  flap  raised  from  the 
lower  lid  is  shifted  outward  and  sutured  to  fill  the  defect. 


Pig.  341. — -The  Argyle  Robertson  strap  operation  for  ectropion  (especially  of  the 
outer  half  of  the  lower  lid)  (Beard,  in  Wood.) — i.  The  dotted  lines  indicate  the  incisions. 
To  shorten  the  lid  remove  a  wedge-shaped  area  of  skin,  tarsus  and  conjunctiva  a  short 
distance  from  the  outer  canthus.  Then  the  flap  of  skin  as  outlined  is  raised  and  the 
ectropion  is  corrected.  2.  The  overlapping  end  of  the  flap  is  removed,  and  the  wounds  are 
sutured. 


370 


PLASTIC    SURGERY 


should  either  be  skin  grafted,  or  be  filled  with  a  pedunculated  or  sliding 
flap  from  the  forehead  or  temple  as,  for  example,  in  Harlan's  operation. 


Fig.  342. — Kuhnt's  operation  for  ectropion  of  the  lower  lid  {Beard,  in  Wood). — An 
elongated  triangular  area  of  skin  is  removed  as  shown  in  the  diagram.  An  incision  is  made 
along  the  lid  margin  inside  of  the  cilia,  and  the  flap  is  loosened.  Closure  of  the  skin  defect 
shortens  the  skin  along  the  lower  lid.  This  can  be  used  in  conjunction  with  Kuhnt's  opera- 
tion of  excision  of  a  wedge  of  the  tarsus  and  conjunctiva. 


Fig.  343. — Truc's  operation  for  ectropion  {Beard,  in  Wood). — A  pedunculated  flap 
of  skin  sufficiently  long  is  raised  from  the  forehead  external  to  the  eye.  It  is  turned  and 
passed  under  the  loop  of  skin  as  shown,  to  fill  the  defect  left  by  relieving  the  ectropion. 
This  closes  the  defect  and  at  the  same  time  supports  the  lid.  The  pedicle  is  cut  ten  days 
later. 


Fig.  344. — Dieflfenbach's  blepharoplasty  in  the  removal  of  a  growth.  It  can  also  be 
used  in  ectropion  {Beard). — i.  The  shaded  area  abc  indicates  the  defect  left  by  the 
excision.  The  dark  lines  bd  and  dc  show  the  outline  of  the  lateral  flaps  which  are  shifted 
toward  the  midline  to  cover  the  defect.  The  dotted  line  shows  the  area  to  be  undermined 
in  reducing  the  size  of  the  surrounding  defect.  2.  The  flap  shifted  inward  and  sutured  into 
the  defect.      The  remaining  raw  surface  should  be  grafted. 

This  is  an  excellent  method,  and  with  modifications  can  be  used  in 
many  situations,  especially  on  the  lips  (Figs.  344,  345  and  346). 


SURGERY    OF    THE    EYELIDS 


371 


12  3 

Fig.  345. — Harlan's  modification  of  Dieffenbach's  flap  sliding  operation  (Beard). — 
I.  The  dark  lines  indicate  the  incisions.  2.  The  V-shaped  wedge  of  skin  with  the  growth 
has  been  removed.  The  external  flap  has  been  shifted  in  to  cover  the  defect,  leaving  a 
triangular  defect.  3.  By  undercutting  the  skin  edge  and  suturing,  and  by  sliding  down 
the  upper  flap  the  triangular  defect  is  closed,  leaving  a  small  uncovered  area  at  the^outer 
angle  of  the  eye,  which  may  be  grafted. 


I    I    >   I    > 


i — I — ^    I    I    I    I     I   )   ) 


A  B 

Fig.  346. — Knapp's  flap  sliding  operation  for  the  repair  of  a  quadrangular  defect  of  the 
lower  lid  (Beard). — A.  The  shaded  area  indicates  the  extent  of  the  excision.  The  dotted 
lines  show  the  incisions  outlining  the  flaps.  B.  The  flap  shifted  inward  and  sutured.  Care 
must  be  taken  to  have  the  flaps  sufficiently  wide,  as  the  stretching  may  cause  narrowing  to 
such  an  extent  that  subsequent  operations  may  be  necessary  to  correct  the  deformity. 


Fig.  347. — Tweedy's  operation  for  ectropion  (Beard,  in  Wood). — i.  The  dotted 
lines  indicate  the  incisions.  The  flap  A  including  a  section  of  the  conjunctiva  and  tarsus 
about  0.8  cm.  (about  3-3  inch)  wide  is  raised.  The  ectropion  is  corrected  by  dissecting  up 
the  skin  along  the  incision  B.  2.  The  flap  A  is  then  shifted  into  this  defect  and  sutured. 
If  it  is  necessary  to  use  the  tip  of  mucosa  on  the  end  of  the  flap  to  close  the  defect,  it  can 
be  removed  subsequently. 


I 


372 


PLASTIC    SURGERY 


The  flap-sliding  operation  of  Dieffenbach,  Harlan's  modification, 
and  Knapp's  operation,  may  be  used  for  the  formation  of  a  new  lid, 
as  well  as  for  the  relief  of  ectropion,  but  in  my  opinion  the  section  of  the 
flap  forming  the  lid  itself  should  be  lined  with  epithelium,  if  the  full 
thickness  of  the  lid  is  to  be  restored. 


Fig.  348. — Lagleyze's  operation  for  ectropion  of  the  lower  lid  {Beard,  in  Wood). — 
I.  The  dotted  lines  mark  the  outlines  of  the  flaps  A  and  B.  2.  After  the  flaps  have  been 
dissected  up  and  the  ectropion  relieved  they  are  superimposed  and  sutured  in  the  position 
shown. 


RESTORATION  OF  EYELIDS 

The  absence  of  the  eyelids,  in  whole  or  in  part,  is  due  to  direct 
trauma,  to  the  excision  of  malignant  growths,  to  destruction  following 
disease,  syphilis,  tuberculosis,  ulcer,  gangrene. 


?^=^^^\^V\v 


Pig.  349. — Denonvilliers'  operation  for  ectropion  of  the  outer  third  of  the  lower  lid 
{Beard,  in  Wood). — i.  The  dotted  lines  indicate  the  incisions  to  form  the  flaps  A  and  B. 
2.  The  flaps  are  dissected  up.  The  ectropion  is  corrected  and  the  flaps  are  transposed  and 
sutured. 


A  number  of  operations  have  been  devised  for  restoring  the  lids, 
among  them  Gibson's  and  Monks'. 

Gibson's  Operation.— An  incision  is  made  through  the  whole  thick- 
ness of  the  skin  from  the  external  canthus,  in  an  outward  and  slightly 
upward  direction.     The  length  of  this  incision  is  determined  by  the 


SURGERY   OF   THE   EYELIDS 


373 


^^#^^S^^  ,^^^^^="^^=5:^ 


^i(h^''P'^'^y;>=s, 


Fig.  350. — Gibson's  operation  for  the  restoration  of  the  lower  lid  by  the  use  of  a  pre- 
grafted  gliding  flap  {Annals  of  Surgery.  June,  1914). —  i.  The  area  A  outlined  by  the 
dotted  line  is  undercut.  2.  The  pocket  is  lined  with  an  Ollier-Thiersch  graft,  with  its  raw 
surface  against  the  skin.  3.  The  growth  has  been  excised.  The  flap  A  has  been  loosened 
by  horizontal  incisions. 


Fig.  351. — Gibson's  operation,  continued.— i.  The  lined  flap  being  drawn  inward  to 
fill  the  defect.  2.  The  completed  operation.  In  preparing  such  a  flap^it  is  important 
to  plan  for  the  narrowing  which  follows  stretching. 


Fig.  352. — Restoration  of  an  eyelid  by  the  use  of  a  flap  whose  pedicle  consists  of  the 
anterior  temporal  vessels  (Monks). — i.  Defect  in  eyelid  following  excision  of  an  epi- 
thelioma. The  dark  lines  indicate  the  incisions  outlining  the  flap  and  to  expose  the  vessels. 
The  anterior  branch  of  the  temporal  artery  is  shown  by  the  wavy  dotted  line.  2.  The 
vessels  exposed.  3.  The  flap  dissected  out  with  its  blood-vessel  pedicle.  A  tunnel  is 
being  made  beneath  the  normal  skin  between  the  incision  and  the  lid  defect. 


374 


PLASTIC    SURGERY 


amount  of  eyelid  to  be  removed.  (For  the  operation  described,  in 
which  half  the  lower  eyelid  was  removed,  an  incision  4.375  cm.  (i^^ 
inchesj  long  was  used.)     Through  this  incision  the  skin  is  undercut  and  a 


Fig.  353. — Monks'  operation  for  the  restoration  of  an  eyelid,  continued. —  i.  Drawing 
the  flap  through  the  tunnel.  2.  The  flap  sutured  into  the  defect  and  the  incisions  closed. 
The  dotted  lines  indicate  the  position  of  the  vessel  pedicle,  and  of  the  vessels  in  the  flap. 

pocket  is  made,  which  has  the  outline  of  the  proposed  flap.  The  skin 
side  of  the  pocket  is  lined  with  a  single  Ollier-Thiersch  graft,  which  over- 
laps the  edge.     After  ten  days  the  growth  is  removed  with  the  neces- 


_-.^-^v^ 


Fig.  354. — Operation  for  the  restoration  of  the  lower  lid  (Langenbeck). — i.  The 
shaded  area  indicates  the  defect.  The  flap  X  is  marked  out  by  the  dark  lines.  2.  The 
flap  shifted  into  the  defect.  3.  The  defect  from  which  the  flap  was  raised  may  often  be 
sutured  after  undermining  the  adjacent  skin. 

sary  amount  of  lower  lid  by  a  quadrilateral  incision.  The  lined  flap 
is  loosened  by  an  incision  parallel  to  the  original  skin  incision,  and  is 
slid  over  the  defect  and  sutured  (Figs.  350  and  351). 

Monks'  Operation.— He  constructed  a  lower  lid  with  a  carefully 


SURGERY    OF    THE    EYELIDS 


375 


Fig.  355. — Fricke's  operation  for  cicatricial  ectropion  of  the  upper  lid  (Beard). — This 
operation  is  especially  adapted  to  cases  in  which  the  tarsus  and  the  conjunctiva  are  intact. 
The  ectropion  has  been  relieved,  leaving  an  ov^al  raw  area.  The  dotted  line  shows  the 
outline  of  the  flap.  The  skin  between  the  defects  after  raising  the  flap  should  be  removed 
sufl&ciently  to  receive  the  pedicle.  The  defect  from  which  the  flap  is  raised  should  be 
closed  by  undermining  and  suturing,  or  by  c-kin  grafting. 


Fig.  356. — The  flap  b  is  taken  from  the  nose  and  forehead  for  restoration  of  the  lower  lid. 
The  greater  part  of  the  defect  being  on  the  inner  side. 


Fig.  357. — The  same  procedure  with  the  flap  from  the  outer  side,  and  differently  shaped  to 

meet  conditions. 
Figs.    356  .\xd  357. — Blasius"    operations    for  the  restoration  of    the    eyelid  (Beard). 


376 


PLASTIC    SURGERY 


jneasured  flap  from  the  forehead,  whose  pedicle  consisted  of  the  anterior 
branch  of  the  temporal  artery  and  vein  with  the  surrounding  sub- 

I 


Fig.  358. 


r-^m^^^ 


Pig.  359. 
Figs.  358  and  359. — Hasner's  operations  for  the  repair  of  an  angular  loss  of  substance, 
external  or  internal,  by  the  use  of  a  split  or  notched  flap  (Beard). — The  dotted  lines  indi- 
cate the  incisions  outlining  the  flaps,  and  for  the  excision  of  the  growth.  The  bifurcated 
flap  b  is  raised  from  the  outer  or  the  inner  side,  depending  on  the  situation  of  the  loss  of 
substance,  and  is  transplanted  and  sutured  as  shown  in  the  diagrams. 


I  2  3 

Fig.  360.— Richet's  operation  for  the  restoration  of  the  commissure  (Beard).— i.  The 
dotted  lines  show  the  incision  for  removal  of  the  growth.  2.  Shows  defect  left  by  excision. 
The  dotted  lines  indicate  the  outline  of  the  flaps.  The  lower  lid  is  drawn  up  over  the 
upper  lid,  in  an  over-corrected  position.  3-  The  flaps  superimposed  and  sutured  into 
position, 

cutaneous  tissues.     The  flap  was  brought  into  position  by  passing  it 
through  a  tunnel  burrowed  beneath  the  skin  between  the  proximal  end 


SURGERY  OF  THE  EYELIDS 


377 


of  the  pedicle  and  the  defect.     In  finishing,  all  incisions  are  closed  as 
far  as  possible  (Figs.  352  and  353). 

I  would  suggest  that  the  under  surface  of  the  flap  be  pregrafted 
before  transplanting,  to  avoid  contracture,  and  that  it  be  freely  scarified 
when  transplanted  to  reduce  early  congestion. 


^^^^^^^    ^^^% 


Fig.  361. — Landolt's  double-pedicled  flap  for  the  restoration  of  the  lower  lid  (^eard, 
in  Wood). — I.  The  defect  on  lower  lid  B.  The  dotted  lines  outline  the  flap  A.  2.  The 
flap  raised  and  shifted  to  cover  the  defect  in  the  lower  lid.  Note  the  raw  surface  on  the  upper 
lid.  3.  Flap  sutured  into  position.  The  raw  surface  on  the  upper  lid  is  closed.  The 
pedicles  are  divided  after  ten  days  and  fitted  into  position. 

3.  By  Pedunculated  Flaps  from  Neighboring  Skin. — The  principles 
of  the  use  of  pedunculated  flaps  have  been  considered  in  a  previous 
section. 


'/'nTj<frn*F 


Pig.  362. — Rollet's  operation  for  the  restoration  of  the  upper  lid  {Beard,  in  Wood). — 
r.  The  defect  in  the  upper  lid.  The  dotted  lines  mark  the  incisions  for  the  flaps  A  and  B. 
2.  The  flaps  are  raised,  turned  inward  and  are  superimposed.  The  defects  left  by  raising 
the  flaps  may  be  sutured. 

The  use  of  this  method  by  Fricke,  Blasius,  Hasner,  Richet,  Landolt, 
and  others,  will  not  be  described  in  detail,  the  plates  being  sufiiciently 
explanatory. 

4.  Pedunculated  Flaps  from  Distant  Parts. — Eyelids  ha\e  been 
formed  from  pedunculated  flaps  from  the  arm  (Berger  and  others), 
and  neck  (Syndacker-Morax,  and  others).     By  the  use  of  these  flaps 


378 


PLASTIC    SURGERY 


scarring  of  the  face  is  avoided  and  normal  tissue  is  secured  in  those 
cases  in  which  the  face  is  covered  with  scar. 

Pedunculated  flaps  of  this  type  may  be  used  for  the  relief  of  ectro- 
pion, when  the  tarsal  cartilage  and  conjunctiva  are  present,  and  also  for 
the  restoration  of  the  lids.  In  the  latter  case  it  is  essential  that  the 
flaps  be  lined  with  epithelium  to  prevent  subsequent  adhesion  and  con- 
tracture. This  can  be  accomplished  either  by  turning  the  end  of  the 
flap  on  itself  (which  makes  a  thick  and  clumsy  flap),  or  by  preliminary 
grafting  of  the  raw  surface  of  the  flap. 


Fig.  363. — Syndacker-Morax  method  of  utilizing  a  pedunculated  flap  from  the  neck  for 
the  restoration  of  one  (Syndacker)  or  both  (Morax)  eyelids  (Beard,  in  Wood). — i.  The 
outline  of  the  flap  with  its  base  beneath  the  ears  to  be  raised  from  the  skin  over  the  sterno- 
cleidomastoid muscle.  It  should  be  sufficiently  long  to  cover  the  lid  defect  without  ten- 
sion. Note  the  defect  nearly  encircling  the  eye.  2.  The  flap  raised  and  sutured  into  the 
upper  lid  defect.  The  neck  wound  is  sutured.  3.  The  pedicle  of  the  flap  is  severed  after 
two  weeks,  and  the  unattached  portion  of  the  flap  is  adjusted  and  sutured  into  the  rest 
of  the  defect. 


The  ideal  lining  of  these  flaps  would  be  mucous  membrane,  but  as 
yet  no  satisfactory  technic  has  been  developed  for  its  use.  It  is  possible 
that  the  application  of  a  flap  of  buccal  or  vaginal  mucosa  placed  in  a 
pocket  in  some  such  way  as  is  described  in  Gibson's  operation,  might 
be  worth  trying.  In  any  case,  the  result  of  thin  Ollier-Thiersch  graft- 
ing is  so  good  and  the  epithelium  adjusts  itself  to  its  new  environment  so 
promptly,  that  the  more  uncertain  procedure  of  mucous  membrane 
grafting  seems  unnecessary. 

In  all  cases  the  area  from  which  the  flap  is  raised  should  be  either 
sutured  or  grafted. 


SURGERY  OF  THE  EYELIDS  379 

PREPARATION  OF  NEW  SOCKET  FOR  AN  ARTIFICIAL 

EYE 

The  object  at  which  we  aim  when  an  eye  is  enucleated  aseptically, 
is  to  prepare  a  movable  stump  on  which  the  artificial  eye  can  rest  and 
move  in  coordination  with  the  normal  eye.  This  is  best  accomplished 
by  implanting  free  fat  in  Tenon's  capsule  (at  the  time  of  enucleation), 
by  Barraquer's  method  or  some  modification  of  it. 

Sometimes  infection  will  occur,  or  the  eye  may  be  destroyed  by 
trauma  or  disease,  so  that  the  proper  preparation  for  the  artificial  eye 
becomes  impossible.  In  these  cases  the  orbital  cavity  behind  the  lids 
may  be  obliterated  by  scar  and  the  lids  become  adherent. 

On  several  occasions  I  have  been  asked  to  prepare  a  cavity  for  the 
reception  of  an  artificial  eye  in  such  cases.  This  is  always  a  difficult 
task  and  many  trials  may  be  necessary. 

The  most  satisfactory  results  in  my  hands  have  been  obtained 
(after  freeing  the  lids)  by  excavating  a  cavity  somewhat  larger  than 
the  eye  to  be  inserted.  Then  line  this  cavity  with  Ollier-Thiersch 
grafts,  which  are  anchored  here  and  there  with  fine  silk  sutures;  then 
an  eye  similar  to,  but  of  larger  size  than  that  to  be  worn  permanently 
(which  has  been  previously  rendered  aseptic)  is  inserted  to  splint  the 
grafts,  the  lids  are  closed  with  sutures,  and  a  dressing  is  applied. 

Another  method  is  to  cover  an  artificial  eye  with  a  single  Ollier- 
Thiersch  graft,  raw  side  out,  secured  by  sutures,  and  insert  it  into  the 
cavity.  The  artificial  eye  in  both  methods  is  not  removed  for  at  least 
one  week,  and  preferably  for  ten  days.  It  is  then  taken  out  with  great 
care  and  cleaned.  The  stitches  are  removed,  and  after  gentle  irriga- 
tion of  the  graft  lined  cavity  with  normal  salt  solution,  the  same  eye  is 
again  inserted.  The  cavity  after  grafting  may  be  filled  with  melted 
parafitin,  and  the  same  post-operative  routine  carried  out,  but  my  pref- 
erence is  for  the  glass  eye.  After  three  weeks  the  normal  sized  eye  is 
inserted,  and  except  for  daily  cleaning  is  kept  in  place  continuously  for 
six  weeks,  after  which  the  usual  routine  of  nightly  removal  is  com- 
menced. 1^ 

CANTHOPLASTY  (LENGTHENING  THE  PALPEBRAL 

OPENING) 

Canthoplasty  is  a  very  important  procedure  (either  primary  or 
secondary),  in  many  of  the  plastic  operations  on  the  lid;  it  has  for  its 
object  the  lengthening  of  the  outer  commissure. 


38o 


PLASTIC    SURGERY 


Agnew's  Operation.  (^Modification  of  von  Amnion's  Operation.) — 
With  strong  scissors  the  outer  commissure  is  lengthened  for  from  i.  to 
1.5.  cm.  (75  to  3.5  inch).  The  canthal  Hgament  (above  and  below)  is 
divided  with  very  fine  scissors.     A  needle  is  placed  in  the  conjunctival 


Fig.  364. — Von  Ammon-Agnew's  operation  for  canthoplasty  (Beard). — The  'pal- 
pebral fissure  has  been  lengthened,  and  the  external  canthal  ligament  divided.  Note  the 
position  of  the  sutures  so  placed  that  they  prevent  stretching  of  the  conjunctiva,  and  oblit- 
eration of  the  external  cul-de-sac. 


angle  and  is  carried  outward  as  far  as  it  will  go  without  stretching  the 
conjunctiva,  and  is  passed  through  the  upper  lip  of  the  wound  (not  to 
the  external  angle  of  the  skin  incision,  if  it  would  cause  too  much  ten- 


I  2 

Fig.  365. — Abnormal  narrowing  of  the  palpebral  slit. — i.  Before  operation.  The 
history  of  the  case  is  that  the  lids  were  united  at  birth,  but  were  opened  slightly 
during  infancy.  2.  After  operation.  The  canthi  were  lengthened  externally  and  inter- 
nally, and  an  elongated  ellipse  of  skin  was  removed  from  between  the  eyes.  The  lid  muscles 
were  atrophied  from  lack  of  use,  but  later  the  patient  was  able  to  open  the  lids  more  widely. 
Photograph  taken  three  months  after  operation. 


sion).  Another  suture  above  and  below  join  skin  and  mucous  mem- 
brane, and  the  operation  is  finished  with  a  single  skin  stitch  if  necessary 
(Fig.  364). 


SURGERY  OF  THE  EYELIDS 


381 


TARSORRHAPHY  (SHORTENING  THE  PALPEBRAL 

OPENING) 

Tarsorrhaphy  is  an  operation  designed  to  shorten  the  palpebral 
fissure;  in  plastic  surgery  this  procedure  is  sometimes  necessary  in 
dealing  with  extensive  ectropion. 

Walther's  Operation. — Strips  of  skin  are  excised  from  the  margins  of 
both  upper  and  lower  lids,  deep  enough  to  include  the  follicles  of  cilia. 
These  denudations  should  extend  as  far  from  the  canthus  as  is  rendered 
necessary  by  the  degree  of  closure  de- 
sired. The  raw  edges  are  united  with 
through  and  through  sutures,  which 
are  allowed  to  remain  for  four  or  live 
days  (Fig.  366). 

Internal  tarsorrhaphy  is  seldom 
necessary  in  plastic  surgery. 

EXENTER.\TION  OF  THE  ORBIT 

Occasionally  it  is  necessary  to  re- 
move the  lids  and  entire  contents  of  the 
orbital  cavity  including  the  periosteum 
(for  malignant  disease) .  In  these  cases, 
unless  something  is  done  to  fill  this 
cavity,  the  contraction  of  the  scar  due 
to  gradual  healing  by  cicatrization  will 
pull  the  surrounding  soft  parts  into  the 
defect— a  result  that  will  cause  great  discomfort  and  hideous  deformity. 

The  immediate  treatment  is  either  to  line  the  cavity  with  Ollier- 
Thiersch  grafts,  which  is  usually  very  unsatisfactory,  or  to  shift  in 
pedunculated  flaps  from  the  forehead  or  cheek. 

The  cavity  may  be  filled  with  a  free  fat  graft,  and  covered  with  a 
pedunculated  flap  from  the  forehead  (Schirmer).  The  method  of 
utilizing  flaps  from  the  forehead,  although  they  often  will  close  the 
defect,  has  the  disadvantage  of  leaving  extensive  unsightly  scars,  and 
this,  of  course,  should  always  be  avoided  as  far  as  possible  in  plastic 
work  on  the  face. 

The  best  procedure  is  to  fill  the  orbit  with  a  thick  pad  of  fat  covered 
by  whole-thickness  skin.  This  is  done  by  the  use  of  a  pedunculated 
flap,  and  a  double  transfer  is  usually  necessary,  since  we  can  seldom  get 
a  sufficiently  thick  pad  of  fat  from  the  arm. 


Fig.  366. — Walther's  operation 
for  external  tarsorrhaphy  (Beard). — 
The  shaded  area  indicates  the  de- 
nuded portion  of  the  lids. 


382 


PLASTIC    SURGERY 


The  method  I  have  used  is  to  implant  the  edge  of  a  pedunculated 
flap  of  fat  and  skin  from  the  abdominal  wall  as  thick  as  is  possible  to 
raise,  into  an  incision  in  the  palm  of  the  hand.     After  the  circulation 


Pig.  367. — Method  of  dealing  with  exenteration  of  the  orbit,  including  removal  of  the 
lids.  The  defect  followed  the  removal  of  a  melanotic  sarcoma.- — i.  Note  the  deep  cavity 
covered  with  granulations  and  the  surrounding  skin  being  drawn  in  over  the  orbital  mar- 
gins. This  caused  intense  discomfort.  The  problem  of  checking  the  pull  of  the  skin  into 
the  orbital  cavity  and  at  the  same  time  filling  the  cavity  had  to  be  considered.  A  flap 
from  the  neck  or  forehead  could  have  been  used,  but  this  procedure  entailed  a  disfiguring 
scar  which  should  always  be  avoided  if  possible.  It  was  decided  to  attempt  to  fill  the  cavity 
by  means  of  a  pedunculated  flap  from  the  abdomen  with  a  double  transfer.  2.  A  flap  com- 
posed of  the  skin  and  full  thickness  of  the  abdominal  fat  was  implanted  into  an  inci- 
sion along  the  ulna  side  of  the  hand.  After  two  weeks  the  pedicle  was  cut  and  the  result 
is  shown  in  the  photograph.  Two  weeks  later,  during  which  time  all  ill-nourished  portions 
were  removed,  the  eye  defect  was  prepared  and,  after  proper  shaping,  the  flap  was  im- 
planted into  the  orbital  cavity,  and  about  two-thirds  of  the  skin  margin  was  sutured. 


Fig.  368. — Exenteration  of  the  orbit,  contimied. —  i.  After  ten  days  the  flap  was  cut 
away  from  the  hand,  and  the  remaining  portion  was  fitted  into  position.  The  photograph 
was  taken  one  week  after  this  and  shows  some  of  the  stitches  in  the  portion  last  sutured. 
2.  Taken  one  j^ear  later.  There  has  been  shrinkage  of  the  fat,  but  the  skin  is  soft  and 
movable  and  all  tendency  to  puckering  and  drawing  in  of  the  face  skin  has  been  eliminated, 
and  there  is  no  discomfort.  The  age  of  the  patient  contraindicated  any  attempt  to  form 
lids  and  prepare  a  socket  for  an  artificial  eye. 


has  been  established  from  the  palm  to  the  flap,  to  amputate  from  the 
abdominal  wall,  then  shape  the  fat  and  transfer  the  flap  on  the  hand 
to  the  defect  in  the  orbit,  which  has  been  prepared  to  receive  it,  and 


SURGERY    OF    THE    EYELIDS 


3^5 


suture  the  skin  edges  to  the  surrounding  skin.  In  due  time  (from  ten  to 
fourteen  days)  the  flap  is  cut  away  from  the  hand  and  the  rest  of  the 
defect  is  closed  (Figs.  367  and  368). 

This  gives  a  result  which  prevents  further  contracture  and  makes 
the  patient  comfortable.  A  certain  amount  of  the  fat  of  the  flap  may 
disappear,  but  even  so  the  result  is  satisfactory  to  the  patient. 

If  further  padding  is  needed  after  healing  is  complete,  the  skin  may 
be  undermined  and  a  free  fat  graft  inserted. 

RESTORATION  OF  THE  EYEBROW 

A  missing  eyebrow  may  be  restored:  (i)  By  the  free  transplanta- 
tion of  whole -thickness  hair-bearing  skin,  from  the  pubcs  or  from  the 


Fig.  369. — Methods  of  reconstructing  eyebrows. —  i.   By  means  of  a  temporal  flap.      2.    By 
means  of  a  frontal  flap  (Morestin). 

scalp.  I  have  used  this  method  with  success,  and  enough  hair  follicles 
have  survived  to  make  the  result  worth  while.  In  planning  the  graft 
"the  set"  of  the  hair  must  be  taken  into  consideration.  The  technic 
is  that  used  for  any  whole-thickness  graft. 

(2)  By  using  pedunculated  flaps  of  hair-bearing  skin,  from  the 
scalp  or  from  the  hairy  portion  of  the  forearm.  Pedunculated  flaps 
from  the  scalp  are  easily  obtained  either  from  the  frontal  or  temporal 
regions,  and  may  be  turned  into  the  defect  without  difficulty.  The 
location  from  which  the  hairy  portion  is  raised  depends  on  the  hair 
line,  which  is  much  closer  to  the  eyebrows  in  some  instances  than  in 
others.     The  flap  may  be  turned  directly  into  the  defect,  or  its  pedicle 


384 


PLASTIC    SURGERY 


may  bridge  normal  skin.  Hairless  skin  from  the  forehead  may  be 
included  in  the  flap  if  necessary  to  repair  defects  in  the  upper  lid 
(Fig.  369). 

Secondary  operations  are  always  necessary  to  shape  the  eyebrow,  in 
order  to  remove  any  excess  of  hair-bearing  skin,  and  to  smooth  out 
any  kink  in  the  pedicle.  Little  scarring  is  noticeable,  as  the  hair  con- 
ceals the  scalp  scar,  and  the  scar  on  the  forehead  can  be  made  quite 
inconspicuous. 

A  pedunculated  flap  from  the  forearm  of  a  hairy  individual  can  be 
transplanted  by  the  Italian  method.  The  utilization  of  this  method 
depends  on  the  hairiness  of  the  skin,  and  thus  limits  its  applicability. 
Secondary  trimming  operations  may  be  necessary  after  amputation 
of  the  pedicle. 


Pig.  370. — Goyanes'  operation  for  restoration  of  an  eyebrow  (Beard). — i.  The 
dotted  lines  mark  the  incisions  made  to  form  the  pedunculated  flap  B.  The  area  A  has 
been  properly  prepared  for  the  reception  of  the  flap.  2.  Shows  the  flap  consisting  of  one- 
half  of  the  normal  eyebrow  sutured  into  its  new  position,  and  all  wounds  closed. 

Both  of  these  pedunculated  flap  methods  are  rational  and  give  good 
results. 

(3)  By  Splitting  the  Intact  Eyebrow  in  Half  and  Transplanting  It  as 
a  Pedunculated  Flap  (Goyanes) . — I  have  used  this  method  with  success. 
The  flap  should  be  as  thick  as  possible,  as  it  is  so  narrow  at  its  extremity 
that  the  blood  supply  may  be  insufficient.  The  scars  are  inconspicuous 
(Fig.  370). 

Ptosis 


Ptosis  of  the  eyelid  is  of  interest  to  the  plastic  surgeon,  since  it  may 
be  due  to  redundancy  of  tissue  after  other  plastic  operations.  In 
these  instances  simple  excision  of  the  slack  skin  and,  if  necessary,  of  an 
ellipse  of  tarsal  cartilage,  with  proper  closure,  is  usually  sufficient  to 
correct  the  deformity. 

The  many  complicated  operations  which  have  been  devised  for 
the  relief  of  congenital  and  paralytic  ptosis,  will  not  be  considered 


SURGERY    OF    THE    EYELIDS 


385 


Fig.  371. — Knapp's  operation  (modified  v.  Ammon)  for  epicanthus. — An  ellipse  or 
diamond-shaped  piece  of  skin  is  excised  from  the  bridge  of  the  nose.  The  skin  is  under- 
mined and  the  edges  are  closed. 


Fig.  372. — Operation  for  epicanthus  (Berger). — An  incision  is  made  from  the  upper, 
and  also  the  lower  parts  of  the  fold,  to  a  point  on  the  nose  in  line  with  the  inner  canthus, 
thus  making  a  V-incision.  From  the  ends  of  this  incision  two  others  are  made  which  con- 
verge at  a  greater  angle  than  the  preceding,  thus  marking  out  the  area  ABCD,  which  is 
excised.     The  edges  are  then  drawn  together. 


Fig.  373- 


-Operation   for  epicanthus   (Desmarres). — An  ellipse  of  skin  is  excised  on  each 
side  of  the  nose,   and  the  skin  is  closed  with  sutures. 


25 


386 


PLASTIC    SURGERY 


Ith. 


Pig.  374. — Excision  of  the  lachrymal  sac. — With  the  thumb  of  the  left  hand  the  skin  is 
fixed,  but  not  pulled  or  stretched.  The  cutting  edge  of  the  knife  is  directed  vertically 
against  the  bone.  The  incision  is  downward,  slightly  outward  and  somewhat  curved, 
0.3  cm.  to  0.4  cm.  (3^^  to  J^  inch)  distant  from  internal  canthus  (Meller). 


Fig.  375. — The  separation  and  pulling  to  either  side  of  the  muscle-fibers  (m.)  exposes 
the  deep  fascia  (f-p.)  in  the  wound;  behind  this  the  sac  must  be  looked  for. — In  the  upper 
angle  of  the  wound  are  the  transverse  fibers  of  the  ligament  of  the  internal  canthus  (I.e.). 
Through  the  fascia  the  anterior  lachrymal  crest  {cy.a.)  can  always  be  felt  and  can  occasion- 
ally be  seen  (Meller). 


SURGERY  OF  THE  EYELmS 


387 


here.     For  detailed  information  on  this  subject  the  reader  is  referred 
to  works  on  Ophthalmic  Surgery. 

Epicanthus 

Epicanthus  is  a  congenital  deformity  in  which  a  fold  of  skin  partly 
covers  the  inner  canthus.     It  may  be  corrrected  by  Knapp's,  Des- 


FiG.  376. — The  deep  fascia  is  incised  throughout  the  entire  length  of  the  wound  0.5  mm. 
behind  (i.e.,  to  the  side  of)  the  crest  (cr.a.).  This  lays  bare  the  bluish-red  lachrymal  sae 
(5a.).  The  lateral  margin  of  the  fascial  wound  (/./.)  is  grasped  with  the  forceps,  and  the 
closed  scissors  made  to  separate  the  loose  areolar  tissue  between  sac  {sa.)  and  fascia,  as 
far  back  as  the  bone  (Meller). 

marres',  or  Berger's  operations  (as  shown  in  the  diagrams),  or  by  some 
modification  of  them. 


The  Relief  of  Occlusion  of  the  Naso -lachrymal  Duct 

Xot  infrequently  in  cases  of  deformity  of  the  nose,  due  either  to 
trauma  or  disease,  the  naso-lachrymal  duct  is  occluded,  and  resists 


388 


PLASTIC    SURGERY 


all  attempts  to  reestablish  its  patency.  This  occlusion  is  evidently 
due  to  destruction  of  the  channel  in  the  bone  itself,  the  lachrymal 
sac  is  always  infected  and,  unless  it  is  milked  frequently,  inflammation 
sets  up  and  pus  collects. 


sa- 


PiG.  377. — The  lower  half  of  the  lateral  wall  of  the  sac  is  dissected  from  the  deep  fascia. 
The  canaliculi  (c.)  are  visible  as  a  bluish  cord  above  (sa.,  sac). — To  cut  the  canaliculi,  one 
blade  of  the  scissors,  which  must  be  applied  parallel  and  close  to  the  lateral  fascia,  is  intro- 
duced far  up  behind  the  canaliculi  (c),  the  other  is  in  front  of  them.  One  cut  severs  the 
canaliculi  {sa.,  sac)  (Meller). 

In  these  cases  it  may  be  advisable  to  refer  the  patient  to  an  ophthal- 
mic surgeon  for  the  removal  of  the  sac  before  other  operative  work 
is  done.  At  times,  however,  conditions  demand  that  this  operation 
be  done  by  the  plastic  surgeon.  An  excellent  procedure  for  the  re- 
moval of  the  lachrymal  sac  is  that  devised  by  Meller,  which  is  fully 
explained  in  the  diagrams. 

BIBLIOGRAPHY 


Adams,  P.     "Practical  Observations  on  Ectropion,"  181 2,  4. 

Agnew,  C.  R.     "Trans.  Med.  Society,  State  of  New  York,"  1875,  265. 

V.  Ammon,  F.  a.     "Zeits.  f.  Aug.,"  i,  s.  529. 


SURGERY   OF   THE    EYELIDS 

Anagnostakis.     "Annal.  d'oculist.  t.,"  xxxviii,  5,  1857. 
Aymard,  J.  L.     "Lancet."    London,  Oct.  27,  1917,  644. 

Barraquxr.     "Archiv  de.  Oftal.  Hisp.-Amer.,"  i,  1901,  82. 
Beard,  Chas.  H.     "Ophthalmic  Surgery,"  1910. 

Wood:  "System  of  Ophthalmic  Operations,"  1911,  ii,  1388. 
Berger,  p.     "Cong.  fran.  de  Chir.  seance  du  9  otobre,  1889,  4  session,  p.  361. 
Berger  &  LoEWY.     "Archives  d'Ophtal.,"  1898,  xviii,  453. 
Blasius.     "Med.  Zeit."     Marz.,  1842. 


389 


Fig.  378. — A  short  transverse  cut  (easily  seen  in  Fig.  379  (/.;,  while  in  this  drawing  it  is 
pulled  to  one  side  by  the  forceps)  into  the  median  margin  of  the  fascial  wound  exposes  the 
anterior  crest  (cr.a.);  this  makes  it  easy  to  push  the  closed  scissors  between  the  bone  and 
sac  (sa.)  at  the  upper  part  of  the  crest  and  to  loosen  the  sac.  The  point  of  the  scissors  is 
directed  toward  the  bone  (Meller). 

Calhoun,  F.  P.     "Jour.  Amer.  Med.  Assn.,"  July  22,  191 1,  279. 

D.wis,  A.  E.     "Jour.  Amer.  Med.  Assn.,"  Nov.  18,  191 1,  1682. 
DENOX\^iLLrERS.     "Bull.  soc.  de  chir.  de  Par.,"  1856-7,  vii,  243. 
Desmarres.     "Traite  d'ophthalmologie,  474. 
Dieffexbach,  J.  F.     "  Chirurgische  Erfahrungen,"  etc.,  1830,  126. 

EssER,  J.  F.  S.     "Anns.  Surg.,"  March,  191 7,  307. 

Fricke.     "Bildung  neuer  Augenlider  nach  Zerstorung,  etc."     Hamburg,  1829. 


390 


PLASTIC    SURGERY 


GiBSOX,  Chas.     "Anns.  Surg.,"  June,  1914,  958. 

GoYAXES  Capde\"xl.\,  J.     "Arch.  de  oftal.  Hispano-Am."     Barcel,  1905,  v,  229. 

V.  Gbaeke.     "Klin.  Monatsbl.  f.  Augenh.,"  1908,  xl\-i,  426. 

H-ABXAN,  G.  C.     Xorris  &  Oliver:  "S3'stem  of  Diseases  of  the  Ej^e,"  1898,  iii,  89 

Bryant  &  Buck:  "American  Practice  of  Surgery,"  iv,  573. 
H.ASXZR.     "Entvrurf  einer  Anatomischen  Begriindung  der  Augenheilkunde." 
Heard,  R.     "Indian  Z\Ied.  Gaz.,"'  1907,  xiii,  217. 


Fig.  379. — The  sac  having  been  freed  on  both  sides,  is  now  for  the  first  time  grasped 
with  forceps  near  its  apex  (t.)  and  separated  from  the  surrounding  structures  with  sharp 
cuts  of  the  scissors  as  near  the  sac  wall  as  possible.  The  upper  margin  of  the  w^ound  is 
lifted  up  with  a  double  tenaculum,     i.,  transverse  cut  into  fascia  (Meller). 

Hoiz,  F.  C.     "Archives  of  Ophthalmology,"  1879,  viii,  249. 
"Archives  of  Ophthalmology,"  1903,  xxxii,  209. 
"Anns,  of  Ophthalmology  and  Otology,"  1896,  467. 
"Anns,  of  Ophthalmology,"  1908,  204. 

Jokes,  Wharton.     "Principles  and  Practice  of  Ophthalmic  Medicine  and  Surgery,"  1856, 

388. 
Jordan'.     "Berlin  med.  Wchnschr.,"  1895,  764. 


SURGERY    OF    THE    EYELIDS 


391 


Knapp.     "Archiv  f.  Augen.  u.  Ohrcnlifilk.,"  iii,  5q. 

"Archiv  f.  Oph.,"  xiii,  183. 
KuHNT.     "Beitrage  z.  Operaliv.  Augenh.,"  1883. 
KusTER.     Krausc,  F.  &  Hcj'mann,  E.  (A.  Ehrenfried):  "Surgical  Operations,"  i,  157. 

Lagleyze.     "Arch.  d'Ophth."     Paris,  1895,  xv,  605. 

Lagrange,  F.     "Bull,  de  I'Academie  de  Med."     Paris,  Dec.  24,  1918,  641. 

Landolt.     "Archiv  d'oph.,"  1885,  492. 

Leischner,  H.     "Surg.,  Gyne.  &  Obst.,"  Dec,  1906,  799. 

Levy,  W.     "Zent.  f.  Chir.,"  Nr.  28,  1915,  489. 


T'^^^^'^k^JJW!^^^^ 


Fig.  380. — The  sac,  having  been  freed  from  the  surrounding  structures  at  all  points 
except  at  its  lowest  portion,  is  grasped  with  the  forceps  low  down;  the  vertically  held 
scissors  are  made  to  cut  away  all  the  tissue  attached  to  its  lateral  wall  as  close  to  it  as  pos- 
sible until  the  naso-lachrymal  duct  is  reached  {Metier). 

Magitot,  .\.     "Bull,  de  rAcadcmie  de  JNIed."     Paris,  May  12,  1914. 

"Clin.  Ophth.,"  1916,  vii,  360. 

"Bull,  de  I'Academie  de  Med."     Paris,  Feb.  6,  191 7,  177. 

Paris  Letter,  "Jour.  Amer.  Med.  Assn.,"  April  28,  1917,  1275. 
Meller,  J.     "Ophthalmic  Surgery,"  1913. 

Monks,  G.  H.     "Boston  Med.  &  Surg.  Jour.,"  Oct.  20,  1898,  385. 
Morax.     "Annals  d'Oculitique,"  Jan.,  1908. 
MoRESTiN,  H.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  Oct.  27,  1915,  1994- 

"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1916,  pp.  525;  1306;  1314;  17°°;  2003. 

"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1918,  1452. 


392  PLASTIC    SURGERY 

Orechkin,  B.  B.     "Russkiy  Vrach."     Petrograd,  xv,  No.  8. 

Panas.     "Mem.  These  de  Paris,"  1873. 
"Maladies  des  Yeux,"  vol.  ii,  155. 
"Archivd'Oph.,"  1882,  208. 

Raia,  V.  L.     "Annals  of  Ophthalmology,"  April,  1911,  299. 
RiCHET.     "Recueil  d'ophthalmologie,"  1873. 
Roberts,  J.  B.     "Surgery  of  Deformities  of  the  Face,"  191 2. 
Robertson,  D.  Argyle.     "Brit.  Med.  Jour.,"  June  11,  1898,  1504. 


Pig.  381. — Operative  field  after  complete  excision.  The  small  portion  of  the  deep 
fascia,  which  has  been  left  behind,  is  seen  hanging  to  the  anterior  lachrymal  crest,  on  it|.the 
transverse  incision  (l.)  is  still  visible.  The  fossa  (f.s.)  is  quite  empty.  The  outer  border 
is  formed  by  the  deep  fascia  (f.p.)  which  is  firmly  attached  to  the  posterior  lachrymal 
crest;  it  is  of  a  white  color  and  has  a  distinct  luster.  Behind  the  anterior  crest  is  the  probe 
which  passes  into  the  nose.  In  cases  following  trauma  or  lues  this  opening  cannot  generally 
be  found — when  it  is  found  it  should  be  thoroughly  curetted  before  closing  the  soft  parts 
(Meller) . 

Rollet.     "Bull.  Soc.  de  Chir.  de  Lyon,"  1903,  vi,  319. 
"Lyon  Med.,"  1904,  cii,  1169. 
"Lyon  Med.,"  1909,  cxii,  674. 

ScHiEMER.     ''Arch.  Ophth.,"  1916,  xlv,  374. 

de  Schweinitz,  G.  E.     "American  Jour.  Ophthal.,"  1896,  xiii,  41. 
Snellen.     "Cong.  Internat.  d'oph."     Paris,  1863. 
Stieren,  E.     "Jour.  Amer.  Med.  Assn.,"  Aug.  15,  1914,  545. 
Stone,  J.  S.     Bryant  &  Buck:  "American  Practice  of  Surgery,"  iv,  667. 
Syndacker,  E.  F.     "Monats.  Blatter,  f.  Augenheilkunde,"  1907,  71. 
"111.  Med.  Jour."     Chicago,  Sept.,  1916,  186. 

Trxjc.     Quoted  by  Wood:  "System  of  Ophthalmic  Operations,"  191 1,  ii,  1431. 
Truc  &  Villard.     "Bull,  et  mem.  Soc.  Franc  d'opht."     Paris,  1896,  xiv,  350. 


SURGERY   OF   THE    EYELIDS  393 

Valois,  G.  &  Roiat:ix,  J.     "Presse  med."     Paris,  Aug.  24,  1916,  375. 
Verxeuil,  H.     "Chinique."     Brux,  1891,  v,  769. 

Walther,  Ph.     "Jour.  Chirurgie  u.  Augen-Heilkunde."     Berlin,  1826,  86. 

Warrex,  J.  M.ASOX.     "Boston  Med.  &  Surg.  Jour.,"  April  14,  1841,  149. 

Weidler,  W.  B.     "Xew  York  ^led.  Jour.,"  Xov.  2,  191 2,  899. 

Wh.artox-Joxe3.     See  Jones,  Wharton. 

Wheeler,  J.  M.     "Amer.  Jour.  Surg.,"  June,  191 7,  167. 

Wilder,  Wii.  H.     Wood:  "System  of  Ophthalmic  Operations,"  191 1,  ii,  1464. 

Wolfe.     ''London  Med.  Times  &  Gaz.,"  June  3,  1878. 


CHAPTER  XVIII 
SURGERY  OF  THE  EAR  (OTOPLASTY) 

Plastic  surgery  of  the  ear  (pinna,  auricle)  deals  with  the  correction 
and  reconstruction  of  congenital  or  acquired  malformations. 


CONGENITAL  MALFORMATIONS 

In  very  rare  cases  the  ear  may  be  entirely  lacking;  more  often  it  is 
only  partially  defective.     The  auricle  may  be  too  large_  (macro tia) , 


Cnira  of  anthelix 

Crus  of  tiie  helir- 
Anterior  incisure" 

Supratragic  tubercle- 
Tragus- 
Intertragic  incisure^ 


Lobule 


Helix 

Auricular  tubercle 
Fossa  of  antihelix 
Fossa  of  helix 


Cymba 


; Concha 


Cavum  j 
Anthelix 
Posterior  auricular  sulcus 

-Helix 


Antitragus 


Pig.   382. — Lateral  surface  of  a  normal  left  auricle  (Morris). 

or  too  small  (microtia);  the  contour  may  be  abnormal;  the  ear  may  be 
smooth,  the  angle  of  the  antihelix  and  the  curl  of  the  helix  being  missing. 
All  of  these  conditions  may  be  either  unilateral  or  bilateral. 

Abnormally  small  ears  are  usually  accompanied  by  other  malforma- 
tions of  the  organ.  Extensive  defects  of  the  auricle  with  normal  form- 
ation of  the  other  portions  are  rare.  It  is  much  more  common  to  find 
the  lobule  absent,  or  poorly  developed. 

394 


SURGERY    OF    THE    EAR 


395 


Auditory  Meatus. — In  extensive  arrest  of  development  of  the  ear 
there  is  usually  atresia  of  the  auditory  meatus,  and  the  skin  over  it  may 
be  dimpled  or  be  perfectly  smooth.  The  atresia  may  involve  only, 
the  cartilaginous  canal,  or  the  canal  through  the  bone  may  also  be 
obliterated. 

I  have  seen  several  of  these  cases.  In  some  the  x-ray  plates  showed 
no  bony  opening;  in  others  there  was  the  possibility  of  a  bony  opening 
being  present.     Taking  into  consideration  the  fact  that  a  normal  tym- 


FiG.  383. — Arteries  of  the  posterior  surface  of  the  ear  (Manchot). — i.  Posterior 
auricular  artery.  2  and  3.  Anterior  branches  of  i.  4.  Temporal  artery.  5.  Anterior 
auricular  artery. 


panic  membrane  is  seldom  if  ever  found,  I  have  not  yet  felt  justified  in 
trying  to  form  a  canal  on  the  chance  of  finding  a  tympanic  membrane. 
In  cases  of  congenital  atresia  the  mastoid  process  is  apt  to  be  imper- 
fectly developed.  Hearing  is  fairly  acute  in  some  of  these  individuals, 
and  is  probably  transmitted  through  the  bone. 

Accessory  Auricular  Appendages. — These  vary  in  size  from  a  very 
small  nodule  to  masses  i.to  2.  cm.  (,^5  to  ^5  inch)  in  diameter.  They 
are  usually  found  on  a  line  extending  from  the  tragus  to  the  angle  of 


396 


PLASTIC    SURGERY 
Helicis  major  Obliquus 


Transversus 


Helix 


Helicis  minor 


Fibrous  band  com- 
pleting fore  part  of 
meatus 


Cauda  helicis 


Antitrago  -helicii 
fissure 


Terminal  fissure 
Isthmus 

Antitragicus  Tragicus    Spine  of      Fissure  of  Santorini 

Lamina  tragi  helix    Cartilage  of  meatus 

Fig.  384. — Lateral  and  medial  surface  of  the  cartilage  of  the  right  auricle  and  its  muscles 

(Morris). 


Fig.  385.  Fig.  386. 

Fig.  385. — Congenital  malformation  of  the  ear. — This  is  not  an  unusual  type  of  this 
deformity.  The  best  procedure  is  to  infold  the  ear  as  far  as  possible  by  incisions  breaking 
the  spring  of  the  cartilage.  The  raw  surface  should  be  grafted  and  the  ear  held  in  the 
corrected  position  until  it  is  healed.  In  this  way  advantage  may  be  taken  of  any  subse- 
quent growth,  and  the  final  operation  done  when  full  growth  is  attained.  In  this  case  the 
external  auditory  meatus  was  occluded,  although  the  X-ray  shows  the  presence  of  a  fora- 
men in  the  bone. 

Fig.  386. — Congenital  deformity  of  the  ear  associated  with  congenital  absence  of  the 
eye.     The  hearing  is  quite  acute  although  the  external  auditory  meatus  is  missing. 


SURGERY    OF    THE    EAR 


397 


the  mouth  and  corresponding  to  one  of  the  transverse  facial  clefts. 
They  consist  of  reticular  cartilage,  fat  and  skin,  and  occur  as  frequently 
with  normal  as  with  abnormal  ears.  I  have  seen  them  on  the  neck 
close  to  the  clavicle.     They  may  be  removed  without  difficulty. 


ACQUIRED  DEFECTS 

Acquired  defects,  due  to  injury  or  disease,  may  vary  in  extent,  from 
total  absence  of  the  ear  to  any  lesser  degree  of  deformity.  The  treat- 
ment of  congenital  and  acquired  defects  is  practically  the  same. 


Fig.  387.  Fig.  388. 

Fig.  387. — Accessory  auricular  appendage  and  malformation  of  the  nose. — Note  the 
typical  accessory  auricular  appendage  in  front  of  the  ear.  A  tumor  can  also  be  seen  on  the 
nose.      This  is  composed  of  cartilage  and  skin  and  has  a  few  long  hairs  growing  on  it. 

Fig.   388. — Deformity  of  the  ear  with  a  large  accessory  auricular  appendage. 

Operations  for  the  reconstruction  of  the  ear  should  not  be  under- 
taken until  the  patient  is  well  grown.  In  those  instances  in  which  the 
auricle  is  small  and  curled  on  itself,  I  usually  attempt  within  the  lirst 
few  months  of  life  to  uncurl  the  auricle,  and  place  it  in  a  position  which 
will  prevent,  as  far  as  possible,  greater  deformity  as  the  organ  develops. 

Several  years  may  elapse  before  the  work  can  be  completed,  as  time 
must  be  allowed  for  shrinkage  and  readjustment  between  operations. 
In  all  reconstructive  or  corrective  operations  on  the  ear,  care  must  be 
taken  to  make  the  two  ears  as  symmetrical  as  possible.  Skin  and  carti- 
lage should  be  conserved  for  use  in  secondary  operations.  When 
removing  the  cartilage  from  the  auricle  the  skin  on  the  opposite  surface 
of  the  ear  must  not  be  buttonholed. 

Preparation. — Either  soap  and  water,  or  the  iodin  technic  may  be 
used  in  preparation  of  the  part.     If  iodin  is  used  the  excess  should  be 


398 


PLASTIC   SURGERY 


Fig.  389. — Partial  destruction  of  the  center  of  the  lobule  due  to  trauma. — The  defect 
was  filled  by  the  use  of  a  pedunculated  flap  from  the  slack  skin  on  the  back  of  the  lobule, 
with  its  pedicle  at  the  margin  of  the  defect.  The  rest  of  the  margin  was  freshened  and  the 
flap  was  sutured  into  place.  The  raw  surface  on  the  back  of  the  lobule  was  undercut  and 
sutured  over  the  flap.  The  appearance  could  have  been  much  improved,  but  the  patient 
was  so  well  satisfied  that  nothing  further  was  done. 


Fig.  390. — Deformity  of  the  ear  following  an  extensive  burn. — i.  The  cartilage  of  the 
upper  portion  of  the  helix  had  been  destroyed  and  that  part  of  the  ear  was  covered  with 
thin  adherent  scar  tissue.  2.  The  cartilaginous  stumps  were  dissected  out  and  the  spring 
was  broken  by  the  necessary  excisions.  The  edges  of  the  cartilage  were  then  sutured  into 
position,  and  the  scar  tissue  closed  over  the  cartilage. 


SURGERY    OF    THE    EAR 


399 


washed  off  with  alcohol.     A  plug  of  sterile  cotton  should  always  be 
placed  in  the  meatus  before  cleansing  or  operating. 

Anesthesia. — M  any  operations 
on  the  ear  itself  can  be  done  under  a 
local  anesthetic,  by  blocking  off  the 
ear,  or  by  infiltration.  If  an  exten- 
sive operation  is  contemplated,  with 
shifting  of  flaps  and  other  manipula- 
tions, a  general  anesthetic  is  desirable. 

Horsehair  is  the  best  suture  ma- 
terial for  the  skin,  and  fine  catgut  for 
the  buried  sutures.  Aseptic  healing 
is  essential,  as  sometimes  perichon- 
dritis and  infection  of  the  cartilage 
occurs,  which  is  always  difficult  to 
control. 

As  far  as  possible  incisions  should 
be  on  the  posterior  surface  of  the  ear. 
The  natural  spring  of  the  ear  cartilage  should  be  broken  by  incision  or 
excision  of  a  portion  in  all  corrective  operations;  otherwise  there  will 
be  stretching  of  the  scar  and  a  partial  recurrence,  at  least,  will  follow. 


Fig.  391. — The  repair  of  loss  of  sub- 
stance of  the  auricle  (C oc  ft  e  ril). — The 
dotted  lines  indicate  the  triangles  to  be 
removed  to  make  possible  the  approxima- 
tion of  the  ends  of  the  helix  .-1  and  A'. 
The  size  of  the  triangle  varies  with  the 
situation  and  shape  of  the  defect  to  be 
closed. 


INJURIES  OF  THE  EAR 

Recent  injuries  of  the  ears  are  seldom  re- 
ferred to  the  plastic  surgeon.  Lacerated 
wounds,  however  extensive,  should  be  carefully 
sutured,  as  cases  have  been  reported  in  which 
the  whole  or  a  part  of  the  ear  have  been  en- 
tirely severed,  and  after  suture  have  healed 
in  place.  Frequently  only  a  small  tag  of  skin 
may  be  left  connecting  the  ear  with  the  scalp. 
In  all  wounds  of  the  ear  care  must  be  taken  that 
the  external  auditory  meatus  is  kept  open.  Ab- 
solutely accurate  suturing  is  essential,  skin  must 
be  sutured  to  skin  and  cartilage  to  cartilage. 

Hematoma  Auris   (Othematoma). — Occa- 
sionally an  early  case  of  hematoma  of  the  ear 
is  seen  before  organization  has  taken  place.     This  is  always  due  to 
trauma  and  usually  is  associated  with  a  fracture  of  the  cartilage.     The 
blood  collects  beneath  the  unbroken  perichondrium,  which  together 


Fig.  392. — Boxer's  ear 
(othematoma).  Duration 
several  years. — In  a  case  of 
this  kind  careful  dissection, 
excision  and  reshaping  of 
the  thickened  and  deformed 
portions  is  necessary. 


400  PLASTIC    SURGERY 

with  the  skin  is  raised  and  forms  a  swelling  of  varying  size  on  the 
outer  surface  of  the  ear.  The  best  treatment  I  have  seen  for  this 
condition  is  that  devised  by  D.  H.  Palmer.  If  organization  has  not 
taken  place  a  small  incision  is  made  into  the  cavity  in  the  most  depend- 
ent portion  of  the  swelling.  The  contents  are  removed  with  a  curette 
and  the  surface  of  the  cartilage  and  perichondrium  is  scraped  until 
smooth.  The  incision  is  closed  except  for  an  opening  just  large  enough 
to  admit  the  end  of  an  eustachian  catheter  connected  through  a  waste 
bottle  with  a  continuous  suction  apparatus.  In  this  way  any  blood  can 
be  removed,  and  the  perichondrium  and  cartilage  are  brought  together. 
The  ear  and  adjacent  tissues  are  anointed  with  sterile  vaselin  and  sur- 
rounded by  a  paste-board  mold,  into  which  is  poured  a  thick  cream  of 
plaster-of-Paris.  This  surrounds  the  ear,  front  and  back,  and  holds 
the  parts  in  absolute  approximation.  The  suction  is  continued  during 
this  process  and  the  catheter  is  rotated  as  the  plaster  hardens,  so  that 
it  can  be  easily  removed,  leaving  an  opening  for  drainage.  The  cast  is 
supported  with  a  bandage  and  is  removed  by  fragmentation  after  ten 
days.     The  results  are  usually  excellent. 

Cauliflower  ear  (boxers',  football  ear)  is  a  condition  which 
follows  the  complete  organization  of  a  hematoma  auris,  with  a  result- 
ing deformity  of  the  ear  which  may  be  considerable.  The  area  occupied 
by  the  original  hematoma  is  filled  with  cartilage,  scar  tissue,  and,  in 
some  cases,  even  with  new  bone.  There  are  thickening  and  distortion 
of  the  contour  of  the  ear  and  obliteration  of  the  fossae  (Fig.  392). 

The  treatment  consists  in  removal  of  the  thickened  tissue,  and  in 
very  pronounced  cases  areas  of  skin  and  cartilage. 

The  size  of  the  damaged  organ  should  be  made  to  correspond  as 
closely  as  possible  with  that  of  the  normal  ear;  the  skin  edges  are  closed 
and  a  small  horsehair  drain  is  inserted.  An  even  pressure  can  be 
maintained  by  filling  all  the  irregularities  on  both  back  and  front  of  the 
ear  with  wet  cotton  over  a  layer  of  gauze  which,  as  it  dries,  makes  quite 
a  good  mold.  A  plaster-of-Paris  cast,  or  a  paraffin  mold  can  also  be 
used. 

Malformation  of  the  Lobule 

Attachments  (Synechia)  of  the  Lobule. — The  inner  border  of  the 
lobule  may  be  attached  to  the  skin  of  the  neck,  either  congenitally  or 
following  burns,  and  often  requires  operation  such  as  those  devised  by 
Binnie  and  by  Kolle,  either  for  cosmetic  reasons,  or  (in  scars)  for  the 
relief  of  tension  (Figs.  393  and  394). 


SURGERY    OF    THE    EAR 


401 


Quite  a  common  deformity  of  the  lobule  is  due  to  the  gradual  or 
forcible  tearing  out  of  ear-rings. 


Fig.  393. — Operation  for  synechia  (Kolle). — i  and  2.  A  curved  incision  AB  is 
made,  outlining  the  proposed  margin  of  the  lobule.  From  the  inner  extremity  of  this  line 
a  vertical  incision  BC  is  made  which  terminates  on  the  skin  surface.      The  triangle  of  tissue 

thus  outlined  is  removed  and  the  edges  are  sutured. 

A  simple  operation  for  correcting  a  defect  in  the  lobule  is  to  excise 
the  cicatricial  edges  of  the  defect  through  the  full  thickness  of  the 
lobule  and  approximate  the  freshened  surfaces.     The  disadvantage  of 


Fig.  394. — Operation  for  the  correction  of  attachment  of  the  lobule  (Binnie). — Deter- 
mine the  line  along  which  the  lobule  should  be  separated.  In  front  of  the  ear  raise  the 
flap  X,  having  its  base  on  the  ear  corresponding  to  the  above-mentioned  line.  On  the 
back  of  the  ear  raise  the  flap  Y,  having  its  base  on  the  neck.  Separate  the  lobule  along 
the  line  AB.  With  the  flap  X  cover  the  defect  on  the  inner  side  of  the  lobule.  Suture 
the  flap  Y  into  the  defect  on  the  neck. 

the  method  is  that  usually  a  notch  is  left.  This  can  be  overcome  by 
either  making  the  incisions  slightly  curved,  or  by  removing  a  small 
wedge  of  tissue  from  each  side,  thus  lengthening  the  suture  line  and  over- 

26 


402 


PLASTIC    SURGERY 


correcting,  very  much  as  when  operating  for  hareHp   (Figs.  397  and 

398). 

Green's  operation  is  rather  complicated,  as  can  be  seen  from  the 
diagrams;  it  was  designed  to  overcome  the  notching  which  follows  the 


Fig.  395. — Adhesion  of  the  lobule  to  the  cheek  following  a  burn. — i .  The  lobule  is  closely 
bound  to  the  cheek  by  a  thick  scar,  and  there  is  sufficient  traction  to  cause  discomfort.  2. 
Result  of  operation  releasing  and  reforming  the  margin  of  the  lobule. 

modified  simple  operation.     The  weak  point  is  the  thin  tip  of  scar  tissue 
which  is  liable  to  slough  (Fig.  399). 

Enlarged  Lobule. — The  lobule  of  the  ear  is  sometimes  considerably 
enlarged,  either  in  connection  with  macro tia;  or  it  may  be  enlarged 


Pig.  396. — Adhesion  of  the  lobule  to  the  cheek  following  a  burn. — i.  The  synechia  in 
this  case  differs  from  that  in  Fig.  395  as  the  lobule  is  stretched  considerably  more,  and  is 
adherent  for  a  greater  distance.  The  sensation  of  tension  and  drawing  is  much  more 
marked.  2.  Result  of  operation.  Note  the  difference  in  the  shape  of  the  lobule  in  these 
two  cases. 


without  any  increase  in  size  of  the  rest  of  the  auricle.  This  malforma- 
tion may  be  corrected  by  the  removal  of  a  wedge  of  tissue  through  the 
full  thickness  of  the  ear,  as  will  be  described  in  Joseph's  operation  for 


SURGERY   OF    THE    EAR 


403 


Fig.  397. — Operation  for  loss  of  substance  in  the  lobule  (Miraidt). — i.  The  shaded 
area  shows  the  scar  excised.  Note  the  tip  A  on  one  side  of  the  defect,  and  the  denuded 
area  on  the  other.     2.   The  tip  A  is  sutured  over  this,  thereby  avoiding  a  notch. 


Fig.  398. — Operation  for  correction  of  lobular  defect. — i.  The  dotted  lines  indicate  the 
incisions  for  the  removal  of  the  cicatricial  margins  of  the  defect  BAG.  2.  The  points  B  and 
C  are  approximated  and  the  wound  is  closed. 


Fig.  399. — Green's  operation  for  correcting  a  lobular  defect  {Kolle). — i.  The  dotted 
line  D  shows  the  incision  for  removing  the  cicatricial  skin.  The  line  AP  marks  out  the 
flap  with  a  thin  marginal  tip  B,  which  is  to  be  used  to  obliterate  the  notch.  2.  The  scar 
is  excised  and  the  edges  are  approximated.  Then  H  is  sutured  to  A,  F  to  G.  The  thin  tip 
B  being  sutured  to  a  denuded  surface  along  the  margin. 


404 


PLASTIC    SURGERY 


Fig.  400. — Operation  for  correcting  an  abnormally  long  lobule  (J.  Joseph). — i.  An 
area  including  the  full  thickness  of  the  lobule,  shaped  as  indicated  in  the  diagram,  is  excised. 
2.   The  edges  DP  and  FC  are  sutured.     Then  DG  to  EG,  and  CB  to  EA. 


Fig.  401. — Gavello's  operation  for  the  reconstruction  of  the  lobule  (Laurens).- — The 
auricle  is  pulled  upward.  In  the  skin  immediately  below  the  stump  a  flap  one-third  larger 
than  the  lobule  to  be  made  as  outlined,  having  its  base  EF  on  the  cheek.  The  upper  inci- 
sion HE  is  straight  and  is  parallel  to  the  border  of  the  defect  C'E'.  The  lower  incision  is  a 
double  half-curve  IDF,  forming  two  scallops  AB,  as  is  shown  in  the  diagram.  The  flap 
is  raised  and  folded  on  itself,  raw  surface  A  behind  to  raw  surface  B,  and  the  posterior  and 
lower  borders  are  sutured.  Then  the  upper  border  CE  is  sutured  to  the  denuded  edge  of  the 
auricle,  on  the  line  C'E'.  The  defect  from  which  the  flap  is  raised  can  usually  be  closed 
after  undercutting  the  surrounding  skin. 


SURGERY    OF    THE    EAR 


405 


Fig.  402. — Xelaton's  method  of  restoring  the  lobule  (Cocheril). — i.  The  shaded  area 
XDE  indicates  the  raw  surface.  The  dark  line  ABC  indicates  the  outline  of  the  flap. 
2.  The  flap  is  raised  and  folded  on  itself  at  EB.  The  point  E  being  sutured  to  X.  The 
dotted  lines  indicate  the  area  of  undercutting  necessary  in  order  to  close  the  gap  left  by  rais- 
ing the  flap. 


Fig.  403. — Operation  for  the  restoration  of  the  lobule  hnodified  from  Xelaton  and  Ombre- 
danne). —  i,2and3.  Aflapconsiderably  wider  than  the  defect  to  be  filled  is  raised  from  the 
skin  behind  the  ear,  with  its  pedicle  on  the  skin  of  the  neck,  on  a  line  with  the  auditory  canal. 
The  flap  is  raised  and  the  free  edge  AB  is  sutured  to  the  freshened  defect  on  the  neck.  A  roll 
of  iodoform,  gauze  is  placed  under  the  flap.  The  wound  on  the  neck  is  sutured.  Ten  days 
later  the  pedicle  is  severed  and  the  flap  is  folded  on  itself,  raw  surface  to  raw  surface,  and 
the  edges  sutured.  Subsequently  a  trimming  operation  is  necessary  to  smooth  the  contour. 
This  is  an  excellent  operation  and  I  have  used  it  with  satisfaction. 


4o6 


PLASTIC    SURGERY 


macrotia ;  or  by  an  operation  also  devised  by  Joseph  which  ehminates 
notching  of  the  tip  of  the  lobule  (Fig.  400). 


/  E  m 

Fig.  404. — Operation  for  macrotia  (Binnie). —  i.  Make  the  incision  AB  through  the 
ear  and  pull  down  the  upper  flap  the  desired  distance.  2.  The  triangle  of  tissue  DCB 
is  removed.  3.  In  order  to  make  the  line  DB  and  AB  oi  equal  length,  excisethe  triangles 
DEB  and  XYZ.      Then  approximate  the  edges  with  sutures. 


Fig.  405. — Operation  for  macrotia  {Martino,  Trendelenburg,  and  J.  Joseph). — i.  A 
wedge  of  tissue  including  the  full  thickness  of  the  auricle  of  the  necessary  size,  DKC  is 
removed.  This  reduces  the  length  of  the  ear.  In  order  to  make  the  edge  DK  correspond 
in  length  with  the  edge  CK,  and  at  the  same  time  to  reduce  the  width  of  the  ear,  the  tri- 
angles EFL  and  GMH  are  removed.  If  the  lobule  is  also  enlarged  this  is  reduced  by  the 
excision  of  the  triangle  of  tissue  ANB.  2.  The  edges  FL  to  EL,  and  GM  to  HM,  are  first 
sutured,  then  the  edges  DK  to  CK,  and  finally  AN  to  BN.  This  is  an  excellent  operation, 
inasmuch  as  it  reduces  the  size  of  the  ear  in  all  its  dimensions. 


Restoration  of  the  Lobule.^ — Absence  of  the  lobule  may  be  due  to 
congenital  maldevelopment;  it  may  also  be  found  as  the  result  of 
operation  for  the  removal  of  a  malignant  growth,  of  ulceration  or  of 


SURGERY    OF    THE    EAR 


407 


Fig.  406.  Fig.  407. 

Fig.  406. — Operation  for  macrotia  (Cocker il.) — The  shaded  areas  indicate  the  portions 
excised  from  the  full  thickness  of  the  ear.  When  sutured,  C  is  brought  to  C,  A  to  A', 
B  to  B',  and  D  to  D. 

Fig.  407. — Operation  for  macrotia  (Cheyne  and  Biirghard). — A  V-shaped  piece  of  the  full 
thickness  of  the  ear  CAB  is  excised  from  the  upper  and  outer  part  of  the  auricle.  The  base 
of  the  wedge  is  at  the  outer  margin  of  the  helix,  and  the  apex  through  the  antihelix.  Corre- 
sponding to  the  margin  of  the  antihelix  a  curved  incision  GAD.  is  made  through  the  full 
thickness  of  the  ear,  and  from  the  extremities  of  this  incision  two  short  curved  incisions  DE 
and  GF  are  made,  which  end  in  the  triangular  defect.  The  tissue  included  by  these  inci- 
sions is  removed.      B  is  sutured  to  C,  F  and  E    to  A. 


Fig.  408. — Operation  for  macrotia  to  avoid  a  disfiguring  notch  (Kolle). — i.  A  sickle- 
shaped  area  of  tissue  AEA'  through  the  thickness  of  the  ear  is  removed.  Its  handle 
ACA'C  is  on  the  level  with  the  upper  border  of  the  zygomatic  process.  The  upper  cur- 
vature of  the  incision  follows  the  inferior  border  of  the  helix  and  extends  well  into  the  fossa 
of  the  helix.  If  the  antihelix  is  large  a  triangular  area  DFD'  is  excised.  The  dotted  line 
B  indicates  the  area  of  helix  which  may  be  removed  if  shortening  is  necessary.  2.  The 
edges  are  closed  and  the  ear  reduced  in  size. 


4o8 


PLASTIC    SURGERY 


trauma.     It  is  of  great  importance  to  the  patient  as  far  as  personal 
appearance  is  concerned. 


Fig.  409. — Operation  for  macrotia  (Kolle). — i.  An  area  of  tissue  ACDD'C'A',  includ- 
ing the  entire  thickness  of  the  ear  is  excised  from  the  upper  outer  portion  of  the  helix, 
and  fossa  of  the  helix.  This  gives  the  outline  of  a  short  wide  two-pronged  fork.  The 
incisions  making  the  prongs  are  slightly  curved,  so  that  when  the  edges  are  sutured  there 
will  be  a  slight  convexity.      2.   Shows  the  edges  approximated. 

Several  excellent  operations  have  been  devised  by  Gavello,  Nelaton, 
Ombredanne,  and  others,  for  the  reconstruction  of  the  lobule.     I  have 


Fig.  410. — Parkhill's  operation  for  macrotia  {Roberts). — i.  A  crescentic  piece  of  the 
full  thickness  of  the  ear  is  removed  from  the  center  of  the  pinna  with  a  tongue-like  process 
extending  from  the  convex  border  of  the  crescent  to  and  including  the  helix.  The  distance 
AB  and  A'B'  should  be  equal.  The  edges  AB  and  A'B'  are  sutured  and  then  the  cres- 
centic defect. 


used  those  of  which  diagrams  are  shown,  with  success.     The  shape  and 
position  of  the  flaps  must  be  modified  to  meet  conditions  (Figs.  401-403). 


SURGERY    OF    THE    EAR 

Macrotia  (Abnormally  Large  Ear) 


409 


The  auricle  is  uniformly  enlarged,  and  the  ear  is  unsightly.     Several 
operations  have  been  devised  by  Schwartze,  Cheyne  and  Burghard, 


Fig.  411. — Gersuny's  operation  for  closing  a  defect  in  the  helix  (J.  S.  Stone). — When 
the  defect  on  the  helix  is  low  down  a  crescentic  piece  of  tissue  should  be  removed  from  the 
most  prominent  and  curving  portion  of  the  ear,  and  not  in  the  area  adjacent  to  the  defect. 
The  edges  are  sutured. 


Fig.  412. — Operation  for  closing  a  defect  in  the  helix  or  reducing  the  size  of  the  ear 
(Gersuny). — A  crescentic-shaped  piece  of  the  ear  BC  is  removed  from  the  outer  part  of  the 
fossa  and  just  inside  the  margin  of  the  helix.  The  outer  upper  border  of  the  excised  crescent 
should  extend  to  the  point  where  the  helix  is  attached  to  the  head.  The  width  of  the 
crescent  should  be  about  two-thirds  of  the  width  of  the  gap  in  the  helix,  AA',  which  is  closed. 
The  ends  of  the  helix  should  be  sutured  first,  and  then  the  crescentic  incision. 

Parkhill,  Kolle,  Gersuny,  Joseph,  and  others,  for  the  correction  of  this 
deformity.     Good  results  may  be  obtained. 


4IO 


PLASTIC    SURGERY 


The  objection  to  Kolle's  second  method,  and  to  both  of  Gersuny's 
operations,  is  that  the  blood  supply  of  the  flap  of  helix  is  endangered 
on  account  of  its  length  and  narrow  pedicle  (Fig.  404-413). 

Microtia  (Absence  of  the  Ear),  Congenital  or  Acquired 

When  the  entire  ear  or  a  large  part  of  it  is  missing,  the  possibility 
of  successful  plastic  reconstruction  is  doubtful,  and  at  best  the  cosmetic 
results  are  only  fair.  Nevertheless,  some  of  my  patients  have  preferred 
to  undergo  the  necessary  discomforts  in  order  to  have  an  ear  made  of 
their  own  tissues. 

Many  years  ago  Szymanowski  proposed  a  procedure  which  has  been 
tried  from  time  to  time,  and  as  far  as  the  incision  goes,  it  seems  to  be 


Fig.  413. — Schwartz's  operation  for  macrotia  (Kolle). — i  and  2.  A  long  crescentic 
shaped  piece  of  tissue  DBD'C  is  removed  from  the  full  thickness  of  the  auricle  in  the  fossa 
of  the  helix.  A  triangle  of  tissue  AEA'  is  then  excised,  its  base  corresponding  to  the 
outer  border  of  the  helix,  and  its  apex  well  within  the  concha.  3.  The  edges  are  closed  as 
indicated. 

the  best  method  of  raising  a  flap  from  adjacent  tissue  for  the  purpose 
of  forming  an  auricle. 

Szymanowski's  Operation  for  Reconstructing  the  Auricle. — An 

incision  is  made  on  the  scalp,  as  shown  in  the  diagrams,  back  of  the 
rudimentary  ear  or  external  auditory  meatus.  This  flap  should  be 
planned  at  least  one-third  larger  than  the  auricle  which  it  is  proposed 
to  make  and  should  consist  of  skin  and  subcutaneous  tissue.  The 
flap  is  dissected  up,  and  is  folded  on  itself  at  the  constricted  portion 
so  that  raw  surface  is  in  apposition  to  raw  surface.  The  margins  are 
sutured  above  and  below.     Close  the  defect  left  by  lifting  the  flap  with 


SURGERY    OF    THE    EAR 


411 


sutures,  as  far  as  possible,  and  graft  the  uncovered  portion.  Support 
the  double  faced  flap  with  gauze  pads.  Later,  by  several  plastic 
operations  the  auricle  is  shaped,  pushed  forward,  and  the  lobule 
formed  (Fig.  414). 


L^);. 


I  234 

Fig.  414. — Operation  for  reconstruction  of  an  ear  {Szymanowski) . — -i.  Make  the  in- 
cision BIMKXLH,  and  dissect  up  the  flap  as  far  as  the  canal  or  rudimentary  ear  in  the 
center,  and  to  the  line  BH  connecting  the  flap  above  and  below  the  canal.  2.  Fold  the 
whole  flap  on  itself  on  the  line  IL,  bringing  raw  surface  to  raw  surface.  The  tip  D  is  then 
brought  to  the  point  B,  and  the  tip  F  to  the  point  H.  The  point  E  to  the  point  O.  3.  After 
healing  is  complete  raise  the  flaps  OPG,  and  STD,  and  place  them  behind  the  auricle  and 
approximate  the  edges.     4.   The  lobule  is  formed  by  subsequent  trimming  operations. 


I  234 

Fig.  415. — Roberts'  operation  for  reconstruction  of  the  auricle  {J.  C.  Beck). — i.  Out- 
line of  the  flap  to  be  raised.  2.  The  flap  folded  on  itself.  Outline  of  the  lower  flap  to  be 
folded  on  itself  after  healing  is  complete  in  the  upper  flap.  3  and  4.  Process  completed. 
The  drawing  idealizes  the  result. 


The  operation  as  it  was  originally  proposed  is  of  little  practical  use, 
but  its  cosmetic  value  can  be  enhanced  by  utilizing  shaped  rib  cartilage 
for  a  supporting  framework. 

I  have  done  this  on  several  occasions  with  a  fair  degree  of  success, 
but  have  as  yet  not  completed  the  ear  on  any  single  case,  as  these 


412 


PLASTIC    SURGERY 


patients  are  still  returning  from  time  to  time  for  further  operative  work. 
Although  it  might  seem  a  simple  procedure  it  is  quite  difhcult  to  keep 
the  main  portion  of  the  flap,  which  is  to  form  the  auricle,  from  adhering 
to  the  head,  except  at  the  margin.  I  have  tried  to  overcome  this  by 
grafting  the  raw  surfaces,  but  without  complete  success. 

The  best  method  is  by  swinging  up  a  pedunculated  flap  from  the 
neck  and  suturing  it  to  the  posterior  portion  of  the  auricle,  after  dis- 
secting it  well  away  from  the  head.     Ten  days  later  the  pedicle  is  cut. 


Pig.  416. — Congenital  malformation  of  the  ear. — i.  The  rudimentary  ear.  There  is 
definite  atrophy  of  the  face  on  the  left  side.  2.  The  normal  ear  is  very  prominent. 
Note  the  deficiency  in  the  mastoid  region  as  compared  with  the  right  side.  3.  The  body 
of  the  prospective  ear  has  been  formed  from  a  flap  raised  from  behind  the  rudimentary 
ear  and  it  has  been  braced  with  pieces  of  cartilaginous  rib.  There  is  much  difficulty  in 
keeping  this  portion  from  close  adherence  to  the  head.  To  overcome  this  a  flap  has  been 
turned  up  from  the  neck,  and  sutured  in  such  a  way  as  to  line  it.  The  flap  in  place.  Note 
the  tooth  picks  inserted  between  the  flap  and  the  head  to  show  the  depth  of  the  lining. 

I  have  transplanted  a  cartilaginous  rib  for  a  framework  at  the  time 
of  raising  the  flap,  including  it  between  the  raw  surfaces  where  the  flap 
was  folded.  At  other  times  I  have  waited  until  the  surfaces  had  grown 
together  and  then  inserted  the  cartilage  in  channels  burrowed  between 
the  flaps.  It  is  difficult  to  secure  these  grafts  so  that  they  will  stay 
in  the  desired  position  (Figs.  416  and  417). 

Another  difficulty  in  using  the  scalp  flap  is  the  presence  of  hair  on 
the  ear,  but  this  can  be  subsequently  removed  with  radium  or  with 
jc-ray.  I  always  attempt  to  utilize  the  rudimentary  ear  and  have  found 
it  useful  in  forming  a  lobule. 

A  new  ear  may  be  reconstructed  by  means  of  pedunculated  flaps 
from  the  arm  or  chest  wall,  or  by  double  transfer  from  abdomen  to  arm, 


SURGERY    OF    THE    EAR 


413 


to  ear.  It  is  advantageous  to  implant  properly  shaped  pieces  of  car- 
tilage into  these  flaps  for  the  purpose  of  support  and  to  allow  the 
graft  to  heal  in  place  before  suturing  the  flap  to  the  head. 

Artificial  Ears 

In  the  majority  of  cases  in  which  total  reconstruction  of  the  ear  is 
necessary,  we  are  justified  in  advising  the  use  of  a  prosthetic  apparatus. 

Artificial  ears  can  be  constructed  quite  perfectly,  and  to  match 
the  normal  ear  exactly.     They  are  made  of  celluloid,  wax.  papier  mache 


Fig.  417. — Congenital  malformation  of  the  ear  continued. — i.  A  posterior  view  of  3  in 
Fig.  416.  2.  Three  weeks  later,  after  severing  the  pedicle.  The  rudimentary  ear  will 
eventually  be  used  to  form  the  lobule.  The  process  of  forming  the  ear  in  this  case  is  not 
nearly  completed,  but  it  might  be  said  that  a  good  start  has  been  made.  A  number  of 
further  operations  will  be  necessary. 

and  rubber.  Recently  a  flexible  ear  has  been  made  of  a  rubber  mixture 
which  is  colored  to  match  the  skin.  They  are  held  in  place  by  adhesive 
paste  and  various  devices,  depending  on  the  size  and  situation  of  the 
stump. 

Losses  of  Substance  in  the  Auricle 

Losses  of  substance  in  the  auricle  are  of  two  kinds:  those  involving 
the  margin,  or  the  margin  and  body,  of  the  auricle,  and  those  in  which 
the  margin  is  intact,  but  the  center  is  perforated.  These  defects  may 
vary  in  size  (Fig.  418). 

Dieffenbach's  operation. — A  horizontal  flap  of  sufficient  size  is 
marked  out  on  the  skin  of  the  mastoid  region,  with  its  base  posterior. 


414 


PLASTIC    SURGERY 


and  the  free  extremity  behind  the  ear  is  raised  and  sutured  into  the 
defect.  After  ten  days  the  pedicle  is  severed  and  the  body  of  the  flap 
is  folded  behind  the  anterior  portion  already  in  place,  and  raw  surface 
is  sutured  to  raw  surface.  The  defect  from  which  the  flap  is  raised  is 
either  closed  with  sutures,  or  is  grafted  (Fig.  419). 

The  hair  can  be  subsequently  removed  with  radium  or  with  x-ray. 
If  the  gap  filled  by  this  flap  is  wide,  and  the  margin  of  the  ear  tends  to 
sag,  a  shaped  piece  of  cartilaginous  rib  may  be  inserted  between  the 
skin  layers. 

Nelaton  and  Ombredanne's  Operation  for  Loss  of  Substance  in  the 
Lower  Portion  of  the  Auricle. — A  flap  of  sufficient  length  and  width  is 
raised  from  the  occipito-mastoid  region  with  its  base  anterior  (behind 


Fig.  418.  Fig.  419. 

Fig.   418. — Perforation  of  central  portion  of  the  auricle  (Cocheril). 

Fig.  419. — Operation  for  loss  of  auricular  substance  {Dieffenhach.) — ^The  peduncu- 
lated flap  A  with  its  pedicle  B  in  the  mastoid  region,  and  its  free  end  behind  the  ear  is  raised, 
and  is  sutured  into  the  defect.  Ten  days  later  the  pedicle  is  cut  and  the  pedicle  end  of  the 
flap  is  folded  so  that  it  covers  the  raw  surface  of  flap  A. 

the  ear) .  It  is  folded  on  itself  (making  the  margin  of  the  ear)  raw  sur- 
face to  raw  surface,  and  its  edges  are  sutured  into  the  loss  of  substance. 
The  defect  made  by  raising  the  flap  is  either  sutured  or  grafted.  After 
ten  days  the  pedicle  is  divided  and  sutured  to  the  inner  border  of  the 
defect.  This  flap  can  also  be  stiffened  with  a  cartilaginous  graft  if 
necessary  (Fig.  420). 

The  cartilage  of  the  ear  may  be  either  partly,  or  completely,  des- 
troyed by  third  degree  burns  and  the  remaining  portion  be  covered 
with  scar  tissue,  or  be  adherent  to  the  mastoid  region.  Sometimes  it 
is  a  difficult  matter  to  separate  the  ear  from  the  head  and  prevent  a 
recurrence  of  the  deformity. 


SURGERY    OF    THE    EAR 


415 


J.  C.  Beck's  Operation  for  Adherence  (Synechia)  of  the  Auricle 
to  the  Mastoid  Region.^(This  procedure  can  also  be  utilized  for  re- 
pairing losses  of  substance.)  Separate  the  adherent  ear  from  the  mas- 
toid surface,  and  pack  the  space  with  gauze  until  granulations  have 
formed.  At  the  same  time  raise  a  pedunculated  flap,  shaped  to  cover 
the  posterior  surface  of  the  auricle  and  the  mastoid  defect,  from  the 
front  of  the  forearm.  Either  arm  may  be  used  for  this  purpose.  Sepa- 
rate the  flap  from  its  base  with  rubber  tissue  to  prevent  adherence  and 
to  allow  thickening.  One  week  later  freshen  the  raw  surfaces,  raise 
the  forearm,  and  suture  the  flap  from  the  arm  to  the  posterior  surface  of 
the  auricle  and  on  the  mastoid  defect.     Secure  with  a  plaster  cast. 


Fig.  420. — Operation  for  loss  of  substance  of  the  auricle  {modified  from  Nelalon  and  Ombre- 
danne). — i.  Shows  the  defect  and  the  outline  of  the  flap  with  its  base  behind  the  ear  on  the 
line  DE.  2.  The  flap  folded  on  itself  raw  surface  to  raw  surface.  3.  The  flap  sutured  into 
the  defect.     After  ten  days  the  pedicle  is  cut  and  sutured  into  the  line  LK. 

Ten  days  later  amputate  the  flap  from  the  arm  and  fit  it  into  the  un- 
covered portion  of  the  defect.  Care  should  be  taken  to  make  a  natural 
fold  at  the  root  of  the  auricle.  The  defect  on  the  forearm  may  be 
closed  with  sutures,  or  at  least  lessened  in  size;  the  remaining  defect 
should  be  grafted. 

The  adhesion  between  the  auricle  and  the  mastoid  region  can  be 
relieved  by  a  pedunculated  flap  turned  up  from  the  neck.  This  is 
an  excellent  method.  I  have  used  whole-thickness  grafts  and  Ollier- 
Thiersch  grafts  with  fair  success,  but  the  pedunculated  flaps  give  the 
best  results. 

Perforations  of  the  Auricle 


Small  perforations  of  the  auricle  can  be  closed  by  properly  shaped 
flaps  of  skin  from  the  ear  itself.     If  the  perforation  is  of  considerable 


4i6 


PLASTIC    SURGERY 


size,  it  should  be  closed  by  means  of  a  pedunculated  flap  from  the 
scalp  or  neck,  turned  on  itself,  as  previously  described  in  other  opera- 
tions.    The  Italian  method  may  also  be  used  in  selected  cases. 


123  4 

Fig.  421. — Partial  reconstruction  of  the  ear  for  a  defect  following  trauma. — Duration 
several  months,  i.  The  extent  of  the  defect  is  well  shown.  Note  that  the  remaining 
portion  of  the  ear  stands  well  away  from  the  head.  2,  3  and  4.  The  reconstructed  portion 
three  months  later.  Several  shaping  operations  will  be  necessary  to  complete  the  work. 
The  flap  to  reconstruct  the  ear  was  obtained  from  the  hairless  portion  of  the  skin  behind 
and  below  the  ear.  The  uninjured  ear  was  also  very  prominent  and  the  cartilage  removed 
from  this  ear  was  utilized  in  preparing  the  framework,  and  the  skin  also  was  employed  for 
filling  defects. 

Retro -auricular  Fistulae  and  Depressions 

Some  of  these  fistulae  are  the  result  of  radical  mastoid  operations 
with  long-continued  drainage.     They  are  lined  with  epithelium  and  are 


12  34 

Fig.  422. — Reconstruction  of  the  anterior  portion  of  the  helix. — i.  Plaster  cast  showing 
the  defect.  2.  Six  weeks  after  shifting  up  a  flap  from  the  hairless  portion  of  the  scalp 
immediately  behind  the  ear,  with  pedicle  above,  and  turning  it  on  itself  to  fill  out  the  defect. 
The  pedicle  has  been  cut  and  the  wound  from  which  the  flap  was  taken  closed.  3.  Two 
months  later,  after  shaping  operations.  4.  Two  and  a  half  years  after  transplantation  of 
the  flap.      The  ear  would  scarcely  be  noticed  as  defective  from  a  distance  of  a  few  feet. 

continuous  with  the  skin;  they  may  open  into  the  external  auditory 
canal,  but  sometimes  there  is  no  such  connection,  the  defect  being  a 


SURGERY   OF   THE   EAR 


417 


Fig.  423. — Trautmann's  operation  for  retroauricular  fistula  (Goldstein). — i  and  2. 
Raise  two  crescentic  flaps  A  and  B  from  the  edges  of  the  fistula,  turn  them  in  and  suture  the 
edges  together,  closing  the  opening.  3  and  4.  Then  undercut  the  skin  all  around  the 
fistula,  and  draw  the  edges  together  with  sutures  over  the  sutured  flaps.  Lateral  relaxa- 
tion incisions  mav  be  necessarv. 


'if/fiitiiiii'' 


I  2  3 

Fig.  424. — V.  Mosetig-Moorhoff's  operation  for  the  closure  of  a  retroauricular  fistula 

(Goldstein). — Raise  a  tongue-shaped  pedunculated  flap  from  the  skin  above  or  below  the 

f.  =  :ula  with  its  pedicle  close  to  the  fistula.     Freshen  and  loosen  the  edges  of  the  fistula 

^":ept  that  adjacent  to  the  pedicle.     Turn  the  flap  over,  epithelial  surface  downward,  and 

-re  it  into  the  margin  of  the  fistula.     The  defect,  from  which  the  flap  is  raised,  is  sutured 

rafted,  and  the  raw  surface  of  the  flap  is  grafted.     Ten  days  later  the  pedicle  is  cut  and 

-  rest  of  the  flap  is  fitted  in. 

27 


4i8 


PLASTIC    SURGERY 


deep  pocket  or  depression,  lined  with  epithelium  which  is  continuous 
with  the  skin. 

A  number  of  operations  have  been  devised  by  Trautmann,  von 
Mosetig-Moorhoff,  and  others,  for  the  closure  of  these  fistulae.  The 
flaps  may  be  varied  according  to  conditions  (Figs.  423  and  424). 

Retro-auricular  depressions  which  do  not  connect  with  the  external 
auditory  meatus  are  treated  as  follows:  The  epithelial  lining  should 
be  completely  removed,  lateral  flaps  being  formed  of  its  upper  portion, 
if  the  tissue  is  sufflciently  thick  to  promise  successful  suturing.  The 
cavity  is  then  filled  with  a  fat,  or  cartilage  graft  (my  preference  is  for 
the  cartilage) ,  and  the  lateral  flaps  are  sutured  over  the  graft.     If  these 


Fig.  425. — Operation  for  the  reconstruction  of  the  external  auditory  canal  (Bouisson) . — 
I.  A  pedunculated  flap  is  raised  from  the  skin  behind  the  ear  with  the  pedicle  above.  2.  A 
stitch  is  inserted  in  the  points  A  and  B  and  the  flap  is  passed  through  a  buttonhole  in  the 
auricle  and  is  sutured  into  the  defect  previously  prepared  to  receive  it.  Thus  forming  a 
canal  lined  with  whole-thickness  skin.  The  defect  from  which  the  flap  is  raised  is  sutured. 
After  ten  days  the  pedicle  is  severed.  The  flap  is  shaped  and  the  buttonhole  in  the  auricle 
is  closed. 

are  uncertain,  then  by  undercutting  with  relaxation  incisions  the  skin 
edges  may  be  approximated.  If  the  defect  is  wide,  it  is  advisable  to 
use  a  pedunculated  flap  from  adjacent  skin,  or  from  the  arm,  to  close 
the  skin  defect. 


Reconstruction  of  the  External  Auditory  Canal 

As  I  have  said  before,  there  is  little  use  in  trying  to  form  a  canal  in 
cases  of  congenital  atresia  of  the  canal  accompanied  by  malformation  of 


SURGERY    OF    THE    EAR  419 

the  ear.  On  the  other  hand,  in  certain  cases  of  atresia  due  to  trauma, 
the  canal  may  be  occluded  at  or  near  its  orifice,  or  be  much  narrowed 
by  scar  tissue.  Tn  these  instances  something  should  be  done  to  remedy 
the  condition.  The  simplest  procedure  but  one  which  is  not  always 
successful,  is  the  excision  of  the  scar,  with  skin  grafting  of  the  canal. 
Ollier-Thiersch  or  whole-thickness  grafts  may  be  used.  The  skin 
lined  canal  is  then  tilled  with  a  paraffin  plug,  which  holds  the  grafts 
against  the  surrounding  tissues.  The  paraffin  may  be  removed  after 
three  or  four  days  for  observation  and  cleansing,  and  should  then  be 
replaced.  In  these  cases,  after  healing  is  complete,  the  canal  should  be 
frequently  stretched  to  avoid  contracture. 

Bouisson  has  devised  a  method  of  reconstructing  the  canal  by  means 
of  a  pedunculated  flap  from  behind  the  ear.     This  type  of  operation  is 


I  2  3 

Fig.  426. — Horizontal  section  of  the  ear  (Luckelt). — i.  Schematic  horizontal  section 
of  normal  auricle  just  above  level  of  external  auditory  canal.  2.  Schematic  horizontal 
section  of  a  prominent  ear  showing  absence  of  the  cartilage  fold  which  forms  antihelix. 
3.   Schematic  section  of  auricle  after  reconstruction  of  antihelix. 

probably  the  best  for  the  purpose  and  may  be  modified  to  suit  condi- 
tions. Other  operations  have  been  done  in  which  flaps  from  the  adja- 
cent skin  have  been  used  (Fig.  425). 


Abnormal  Prominence  of  the  Auricle 

Stone  divides  abnormally  prominent  ears  into  tn'o  groups:  In  the 
first,  the  ear  itself  is  of  normal  shape,  but  is  attached  to  the  head  in  an 
abnormal  position.  In  the  second,  the  prominence  is  due  to  an  ab- 
normality of  the  ear  itself  (Fig.  426). 

He  cafls  attention  to  the  fact  that  many  of  the  malformations 
of  the  ear  depend  upon  the  shape  of  the  antihelix.  There  is  normally 
a  sharp  division  between  the  concha  and  the  fossa  above  and  behind 
the  antihelix  and  if  this  is  missing  the  deformity  results. 


420 


PLASTIC    SURGERY 


These  deformities  may  be  congenital,  or  may  be  acquired  by  young 
children  sleeping  with  the  ear  curled  up,  or  by  having  the  ears  frequently 
rolled  forward  under  a  carelessly  placed  cap. 

Prominent  ears  are  quite  common  and  the  deformity  in  some 
instances  is  so  marked  that  the  patient  is  unable  to  obtain  suitable 
employment.  These  ears  may  be  also  enlarged,  but  quite  often  by 
changing  the  angle  one  can  make  the  size  inconspicuous  and  nothing 
further  will  have  to  be  done  to  correct  the  macrotia. 

Pean's  and  Monks'  Operation  for  Abnormally  Prominent  Auricle.^ 
An  ellipse  of  skin  and  subcutaneous  tissue  is  removed  from  the  back 
of  the  ear  and  adjacent  skin  of  the  mastoid  region.     This  denudation 

should  be  down  to  the  cartilage  and  to  the 
periosteum.  The  shape  and  size  of  this 
area  depends  on  circumstances.  The  skin 
edges  are  sutured  and  the  deformity  is 
corrected.  This  operation  is  advisable 
only  in  cases  of  very  slight  deformity, 
especially  in  young  children  (Fig.  427). 

Cocheril,    Morestin,     Faugere,    Payr, 
Kolle,  and  others,  have  improved  on  this 
procedure  by  the  excision  of  strips  of  carti- 
lage in  addition  to  the  skin;  in  this  way 
breaking  the  resistance  of  the   cartilage 
Pig.  427.— Operation  for  mai-    and  making  the  result  more  certain.     In 
?hf tSal^'i^ftSef .;;;   some  cases  more  than  one  piece  of  cartilage 
amount  of  skin  excised.    The  su-    ig  rcmoved,  according  to  the  degree  of  the 

tures  approximate  the  skin  edges.  . 

deformity. 

After  removal  of  portions  of  cartilage,  the  skin  on  the  anterior 
surface  is  thrown  up  into  a  prominent  fold.  This  fold  will  often  smooth 
down  in  due  time,  otherwise,  it  can  be  removed  without  difficulty  at  a 
secondary  operation.  If  the  denudation  back  of  the  ear  is  too  wide, 
or  if  the  spring  of  the  cartilage  is  not  broken,  we  find  the  retro-auricular 
angle  almost  obliterated.  In  certain  instances  of  defective  auricle 
on  one  side  due  to  injury,  and  a  prominent  ear  on  the  other,  I  have 
utilized  the  cartilage  and  skin  removed  from  the  prominent  ear  in  the 
reconstruction  of  the  other  auricle. 

By  the  removal  of  strips  of  cartilage  with  turning  in  of  the  edges, 
the  antihelix  and  other  prominent  cartilage  land-marks  can  be  recon- 
structed. Care  must  be  taken  to  make  the  two  ears  symmetrical. 
The  ear  should  not  be  made  to  adhere  too  closely  to  the  skull.     Sutures 


SURGERY    OF    THE    EAR 


421 


should  not  be  placed  through  the  cartilage  but  through  the  perichon- 
drium, which  is  quite  tough. 

Kolle's  Operation  (with  Modifications)  for  Abnormally  Prominent 
Auricle. — An  incision  is  made  through  the  skin  on  the  back  of  the 
auricle,  1.875  cm.  {^'4  inch)  from  its  free  border,  from  the  sulcus 
above  downward  to  the  junction  of  the  retro-auricular  skin  with  that 
of  the  neck.  Bleeding  occurs,  and  Kolle  says  that  if  the  ear  is  pressed 
back  against  the  head  the  outline  will  be  marked  on  the  skin,  so  that  the 
second  incision  can  be  made  along  this  line. 


Fig.  428. — Operation  for  correcting  malposition  of  the  auricle  (Kolle). — i.  The 
heart-shaped  black  line  indicates  the  incision  for  removal  of  the  area  of  skin  and  subcuta- 
neous tissue  AA,  from  the  ear  and  scalp.  2.  The  dotted  line  indicates  the  ellipse  of  carti- 
lage B,  to  be  removed.      The  surfaces  are  approximated  and  the  skin  is  sutured. 

My  experience  has  been  that  this  method  of  marking  the  incision 
is  impractical,  on  account  of  too  much  bleeding,  unless  the  first  incision 
is  very  lightly  marked  out  and  does  not  penetrate  the  full  thickness  of 
the  skin. 

The  outline  of  the  entire  flap  is  heart-shaped.  This  area  of  skin 
is  removed  and  should  be  large  enough  to  overcorrect  the  deformity. 
One  or  more  elliptic-shaped  pieces  of  cartilage  are  removed  to  relieve 
tension  and,  when  necessary,  to  reconstruct  the  antihelix.  The  edges 
of  the  cartilage  should  either  be  approximated  or  inverted  (as  the  case 
demands)  with  fine  catgut  sutures  and  the  skin  with  horsehair,  the 


422 


PLASTIC    SURGERY 


ends  of  which  should  be  left  long  for  convenience  in  removing.  Oc- 
casionally it  is  most  difficult  to  check  the  oozing,  and  in  such  cases  a 
small  drain  of  twisted  horsehair  is  placed  in  the  lower  angle. 

A  strip  of  iodoform  gauze  moistened  with  salt  solution  should  be 
placed  over  the  incision  behind  the  ear,  and  the  anterior  surface  filled 
out  with  damp  cotton,  thus  making  a  sort  of  mold  which  is  held  in 

place  by  a  gauze  dressing  and  a 
bandage.  Both  ears  may  be  treated 
in  the  same  way  (Fig.  428). 

Luckett's  Operation  for  Prominent 
Ears. — This  operation  is  based  on  the 
reconstruction  of  the  antihelix.  A 
crescentic  area  of  skin  is  removed 
from  the  posterior  surface  of  the  auricle 
over  the  line  of  the  proposed  anti- 
helix;  the  skin  edges  are  undercut  and 
a  crescentic  area  of  cartilage  of  similar 
size  is  removed.  The  cartilage  edges 
are  closed  in  such  a  manner  that  they 
are  turned  forward,  thus  forming  the 
antihelix.  The  skin  is  closed  with 
horsehair  (Fig.  429). 

Payr's  Operation  for  Prominent 
Auricle  and  Reduction  in  the  Size  of 
the  Ear. — This  operation  will  be  men- 
tioned only  to  advise  against  its  use. 
The  size  of  the  ear  is  reduced  in  all 
its  diameters  by  the  excision  of  skin 
and  cartilage.  The  ear  is  brought 
closer  to  the  head  by  means  of  a 
pedunculated  flap  of  cartilage  and 
perichondrium  which  is  passed  under  a  loop  of  periosteum  in  the  mas- 
toid region. 

This  operation  is  much  more  complicated  than  those  previously 
described  and  has  no  advantage  over  them,  except  that  the  ear  is 
reduced  in  size  at  the  same  time  that  the  angle  is  changed.  The  reduc- 
tion in  size  is  seldom  necessary.  The  flap  of  cartilage  is  also  liable  to 
fracture  during  the  manipulation.  The  cosmetic  results  are  always 
very  poor. 


Pig.  429. — Operation  for  the  cor- 
rection of  abnormally  prominent  ears 
(Luckett.) — AA'  shows  the  crescentic 
area  from  which  the  skin  has  been  re- 
moved. BB'  shows  crescentic  area  of 
cartilage  removed.  The  incision  has 
been  lengthened  and  the  skin  undercut 
and  retracted.  Note  the  method  of  in- 
sertion of  sutures  to  turn  forward  the 
cartilage  edges  to  form  the  new  anti- 
helix. 


SURGERY    OF    THE    EAR 


423 


I  2  .?  4 

Fig.  430. — Bilateral  prominent  lop  ears. — i  and  2.  Front  and  back  views  before 
operation.  3  and  4.  Three  weeks  after  the  reinoval  of  sviflicient  skin  and  cartilage  to 
correct  the  deformity. 


Fig.  431. — Unilateral  prominence  of  the  left  ear,  with  absence  of  the  antihelix. —  i.  The 
front  view  of  the  left  ear  showing  the  absence  of  the  antihelix.  2.  The  posterior  view 
showing  the  abnormal  prominence  of  the  left  ear.  3.  The  re-sult  of  the  removal  of  skin 
and  cartilage,  and  the  attempt  to  reconstruct  the  antihelix.  Front  view  of  both  ears, 
taken  sixteen  months  after  opcratinn. 


Fig.  432. — Unilateral  prominence  of  the  left  ear,  with  absence  01  the  antihelix,  continued- 
I.  Rear  view  of  the  ears  after  changing  the  angle  of  the  left  ear  and  forming  the  antihelix. 
Taken  sixteen  months  after  operation.  The  left  ear  is  now  more  normal  in  its  relationship 
to  the  head  than  the  right.  2.  The  right  ear.  3.  The  left  ear  showing  the  newly  con- 
structed antihelix. 


1234 
Fig.   433. — Bilateral  prominent  ears,   without  absence  of  antihelix. —  i  and  3.   Before 
operation.      2  and  4.    After  excision  of  skin  and  cartilage.      Note  that  the  cartilage  edges 
have  been  united  so  that  there  is  little  abnormal  folding. 


424 


PLASTIC    SURGERY 


Smooth,  Flattened  Ears   (without  Normal!  Cartilaginous  Ridges) 

In  some  instances  we  find  what  may  be  described  as  a  flattened  ear. 
The  curl  of  the  helix  is  absent,  although  a  suggestion  of  it  may  be  present, 
and  the  angle  of  the  antihelix  is  also  missing.  The  auricle  from  the 
front  is  a  flat  surface  and  the  Darwinian  tubercle  may  be  present  on  its 


Fig.  434.— Smooth  ears. 

posterior  superior  edge.     The  ear  appears  larger  than  the  normal  ear 
(Figs.  434-438). 

These  deformities  are  corrected  by  reconstructing  the  curl  of  the 
helix,  and  the  angle  of  the  antihelix.  This  may  be  done  by  excising 
an  ellipse  of  the  skin  on  the  posterior  surface  of  the  auricle,  and  then 


Fig.    435. — Ears   with    abnormal    contours    (Cocheril). — i.  Lop   ear. 

winian  tubercle.-. 


2.  Ear    with   Dar- 


by excision  of  strips  of  cartilage  and  everting  or  inverting  the  edges, 
according  to  whether  the  skin  incision  is  on  the  front  or  back  of  the  ear. 
It  has  been  suggested  to  fold  the  cartilage  and  hold  it  in  position 
with  sutures,  but  my  experience  has  been  that  the  spring  of  the  carti- 
lage will  eventually  overcome  the  correction,  and  a  recurrence  will 


SURGERY    OF   THE    EAR 


425 


follow.     It  is  much  better  to  incise  the  cartilage  or  to  remove  a  strip  of 
it. 

Abnormal  Contour  of  the  Auricle 

In  certain  degenerates,  and  also  in  some  apparently  normal  indi- 
viduals, the  contour  of  the  auricles  is  abnormal.     In  an  accentuated 


''^'^f^T^nBH 

( 

^ 

^ 

^ 

Fig.  436. — Lop  ear  with  an  accessory  auricular  appendage  on  the  cheek  in  front  of  it. — 
I.  The  antihelix  is  missing,  the  rim  of  the  helix  is  very  wide  and  the  ear  projects  almost 
at  a  right  angle  from  the  head.  2.  The  left  ear  is  slightly  abnormal  in  appearance,  and 
projects  markedly  from  the  head. 

form  we  find  the  so-called  "lop  ears,"  and  in  the  less  marked  conditions 
the  appearance  of  the  Darwinian  tubercle.  These  deformities  may  be 
corrected  by  excision  of  the  skin  and  cartilage  in  the  selected  area 
and  by  proper  suturing  (Fig.  436). 


Fig.  437. — Operation  for  correction  of  transverse  hypertrophy  of  the  lobule  (after 
Nelalon  and  Ombredanne).  i.  The  flaps  A  and  B  are  made  from  the  full  thickness  of  the 
margin  of  the  lobule.  A  trapezoidal  area  of  tissue  is  removed.  2.  The  flaps  A  and  B 
are  sutured  to  the  point  C. 

Sometimes  there  is  transverse  hypertrophy  of  the  lobule,  in  which  the 
width  of  the  lobule  is  fully  that  of  the  widest  portion  of  the  auricle. 


426  PLASTIC    SURGERY 

Nelaton's  and  Ombredanne's  Operation  for  the  Correction  of 
Transverse  Hypertrophy  of  the  Lobule. — The  free  border  of  the 
hypertrophied  lobule  is  incised  and  a  flap  is  made  through  the  full 
thickness  of  the  margin  on  each  side,  corresponding  to  the  width  of  the 
lower  portion  of  the  helix.  These  flaps  are  later  to  be  used  as  the 
border  of  the  ear,  after  the  excision  of  the  trapezoidal  piece  of  tissue 
from  the  full  thickness  of  the  ear  (Fig.  437). 

BIBLIOGRAPHY 

AsHHURST,  A.  P.  C.     "Anns.  Surg.,"  Feb.,  1914,  285. 

Beck,  J.  C.     In  Loeb,  H.  W.:  "Operative  Surgery  of  Nose,  Throat  and  Ear,"  1914,  i,  373. 

V.  Bergmanx  (Bull,  W.).     "System  of  Surgery,"  i,  343. 

BiNNiE,  J.  F.     "Operative  Surgery,"  7th  Ed.,  75. 

BoTJissoN.     "Gaz.  med.  d.  Par.,"  1870,  153. 

Braun,  H.  (Shields,  P.).     "Local  Anesthesia,"  1914,  205. 

Cheynte  &  BuRGHARD.     "  Surgical  Treatment,"  iii,  548. 
CoCHERiL.     "These  de  Par.,"  Dec,  1894. 

DiEFFENBACH,  J.  F.     "  Chirurgische  Erfahrungen,  etc.,"  1830,  116. 
Downey,  Jr.,  J.  W.     "Anns.  Surg.,"  Oct.,  1915,  488. 

EiTNER,  E.     "Munchen  med.  Wchnschr.,"  July,  28,  1914,  1681. 

F.AUGERE.     "Congres.  de  Chir.,"  1904,  279. 

Ferreri,  G.     "Policlin."     Rome,  Aug.  15,  1915,  1089. 

Gavello,  G.     Laurens,  Geo.:  "  Chirurgie  Oto-Rhino-Laryngologique."     Paris,  1906,  49. 

Gersuny,  R.     "Wiener  med.  Wchnschr.,"  Nr.  48,  1903. 

Goldstein,  M.  A.     "Laryngoscope,"  1908,  xviii,  826. 

Greene.     Quoted  by  Kolle:  "Plastic  and  Cosmetic  Surgery,"  191 1,    126. 

GucciARDELLO,  S.     "  Policlinico."     Rome,  July  25,  1915,  989. 

Joseph,  J.     "Handbuch  d.  Speziellen  Cnir."     Katz,  Preysing,  Blumenfeld,  Bd.  i,  Heft  2, 

1912,  168. 

KoLLE,  F.  S.     "Plastic  and  Cosmetic  Surgery,"  191 1,  120. 
KosoKABE,  H.     "Arch.  f.  Ohrenh.,"  1913,  Bd.  90,  214. 

LucKETT,  W.  H.     "Surg.,  Gyne.  &  Obst.,"  June,  1910,  635. 
Lynch,  R.  C     "Laryngoscope,"  1913,  xxiii,  1050. 

Martixo.     "Handbuch  d.  Speziellen  Chir."     Katz,  Preysing,  Blumenfeld,  Bd.  i.  Heft  2, 

1912,  168. 
Morris.     "Human  Anatomy."     (Jackson),  5th  Ed.,  1914. 
V.  MoSETiG-MooRHOFF.     " Monatschrift  f.  Ohrenheilkunde,"  1899,  Heft  i. 
MOSHER,  H.  P.     "Trans.  Amer.  Otol.  Soc,"  1913-15,  xiii,  340. 


SURGERY   OF    THE    EAR  427 

Monks,  Geo.  H.     "Boston  Med.  &  Surj^.  Jour.,"  Jan.  22,  1891,  CS4. 

Nel.\ton,  Cu.  and  Ombred.xnne,  L.     "Lcs  Autoplastics,"  1907,  125. 

Palmer,  D.  H.     "Jour.  Amcr.  Med.  Assn.,"  Feb.  5,  1916,  422. 

Parkhill.     Quoted  by  Kolle:  "Plastic  and  Cosmetic  Surgery,"  191 1,  135. 

Payr.     "Arch.  f.  klin.  Chir.,"  1906,  l.xxxviii,  918. 

Pean.     Quoted  by  Nelaton  and  Ombredanne:  "Les  Autoplastics,"  1907,  130. 

Roberts,  J.  B.     "Surgery  of  Deformities  of  the  Pace,"  191 2,  153. 

Schmieden.     "Berliner  klin.  Wchnschr.,"  Aug.  3,  1908,  xlv,  i433- 

SCHWARTZE,  H.     "Die  chirurgischen  Krankheiten  des  Ohres."     Stuttgart,  8vo,  1884-5. 

Stone,  J.  S.     Bryant  &  Buck:  "American  Practice  of  Surgery,"  iv,  717. 

SucHY,  S.     "Wiener  klin.  Wchnschr.,"  Dec.  21,  1916,  1614. 

SzYMANOWSKr,  J.  V.     "  Handbuch  Operativen  Chirurgurie,"  1870,  305. 

Trautmann,  F.     "Archiv  f.  Ohrenheith,"  Bd.  xlviii,  Heft  r,  i. 

Trendelenburg.      "Handbuch    d.    Speziellen     Chir."      Katz,     Preysing,     Blumenfeld, 
Bd.  I,  Heft  2,  1912,  16S. 


CHAPTER  XIX 

SURGERY  OF  THE  EXTERNAL  NOSE 
(RHINOPLASTY) 

Plastic  surgery  of  the  nose  deals  with  the  reconstruction  of  missing 
portions  and  the  correction  of  deformities  due  either  to  congenital 
malformations,  disease,  or  trauma.  It  must  be  emphasized  that  this 
particular  branch  of  plastic  surgery  is  very  difficult,  and  good  cosmetic 
results  are  hard  to  obtain,  no  matter  how  simple  the  defect  may  seem  to 
be. 

Recent  Injuries 

All  wounds  of  the  nose  should  be  sutured  after  proper  disinfection 
and  necessary  excision  of  dead  tissue,  as  scarring  and  subsequent  de- 
formity may  in  this  way  be  minimized.  Where  there  is  extensive  loss 
of  tissue  every  effort  should  be  made  to  save  what  remains,  especially 
the  columna  and  alae,  since  these  portions  are  difficult  to  reconstruct. 
The  suturing  of  skin  to  mucous  membrane  in  favorable  situations  will 
prevent  subsequent  contraction,  and  properly  placed  traction  sutures 
may  also  be  of  use.  Final  reconstruction  cannot  be  accomplished  until 
the  wounds  have  healed. 

Replacement  of  the  Nose 

Several  cases  are  on  record  in  which  a  nose  which  has  been  com- 
pletely severed  has  survived  after  being  replaced  and  held  in  position. 
Although  such  results  may  not  be  the  rule,  it  is  always  advisable  to 
replace  the  severed  portion  (after  proper  cleansing),  and  suture  it  care- 
fully as  soon  as  possible  after  injury.  Should  the  replaced  portion 
live,  the  result  will  be  much  better  than  can  be  expected  from  any 
reconstructive  operation. 

The  oldest  method  of  forming  a  nose  was  by  the  use  of  a  free  graft 
from  the  skin  of  the  buttock.  This  was  done  in  India  before  the  pedun- 
culated flap  from  the  forehead  was  tried,  and  several  successful  cases 
have  been  reported  within  the  last  one  hundred  years.  The  method 
of  forming  a  nose  from  free  grafts  of  skin  is  extremely  uncertain,  on 

428 


SURGERY  OF  THE  EXTERNAL  NOSE 


429 


account  of  insufficient  blood  supply,  the  liability  to  infection,  and  other 
accidents,  and  is  scarcely  worthy  of  a  trial.     In  former  times  noses  have 


Lacrimal  groove  — -.   ^ 


Groove   on   anterior   border   of 
nasal  septal  cartilage 

Sesamoid  cartilages 
Lesser  alar  cartilages 

Cellular  tissue  of  ala 


Nasal  bone 

Nasal  process  of  the  maxilla 


:jr — Lateral  nasal  cartilage 


Literal  crus  of  greater 
alar  cartilage 


% 


Fig.  438. — Anterior  view  of  the  external  nose,  showing  its  cartilages  (Morris). 


Nasal  bone 
Nasal  process  of  the  maxilla 

Lateral  nasal  cartilage 
Nasal  septal  cartilage 


Lateral  eras  of  greater  alar 
cartilage 


Medial  eras  of  greater  alar 
cartilage 


Sesamoid  cartilages 
Fibrous  tissue 
Lesser  alar  cartilages 

—Cellular  tissue  forming  ala 


Fig.   439. — Left  side  of  the  external  nose,   showing  its  cartilages  (Morris). 

been  transplanted  from  one  person  to  another,  with  a  certain  amount 
of  success.     This  method,  even  if  practicable,  would  be  almost  impos- 


430 


PLASTIC    SURGERY 


sible  to  carry  out  in  a  civilized  community  in  time  of  peace,  as  it  is 
seldom  that  any  individual,  however  needy,  would  be  willing  to  part 
with  his  nose,  but  in  war  time  it  might  be  done  with  little  difficulty. 
My  own  feeling  is  that  it  is  practically  useless  to  waste  time  on  this 
method,  as  the  chances  of  success  are  small. 


Nasal  septal  cartilage 


Lateral  crus  of  greater 
alar  cartilage 


Medial  crus  of  greater 
alar  cartilage 


Anterior  nasal  spine 
of  the  maxilla 


Nasal  septal  cartilage 


&  Cellular  tissue  of  ala 


Fig.  440. — Inferior  view  of  the  external  nose,   showing  its  cartilages  (Morris). 

Losses  of  Substance 

Loss  of  substance  may  be  on  the  side  or  on  the  bridge  of  the  nose. 
The  destruction  may  be  superficial  or  through  the  thickness  of  the 
nose,  and  may  be  slight  or  extensive.  The  superficial  destructions  are 
best  treated  with  skin  grafts,  or  with  sliding  flaps,  according  to  the 


I  2  3 

Fig.  441. — Operation  for  the  closure  of  a  lateral  nasal  defect  (Cole). — i.  The  dotted 
line  indicates  the  hinged  flap  which  is  turned  in  and  sutured  to  line  the  cavity.  2.  The 
flap  in  position.  3.  A  scalp  flap  covering  the  raw  surface.  The  flaps  are  closely  held 
together  with  mattress  sutures.  Later  the  pedicles  are  severed  and  the  ends  fitted  into 
position. 


situation.  If  there  is  perforation  and  the  opening  is  small,  the  edges 
may  be  turned  in  and  the  defect  covered  with  a  sliding  flap.  If  the 
opening  is  large,  a  double  flap  may  be  necessary  from  the  cheek  and 
forehead,  one  lining  the  defect,  the  other  covering  the  surface.  If 
the  defect  is  on  the  bridge  of  the  nose,  or  if  the  transplanted  soft  parts 


SURGERY  OF  THE  EXTERNAL  NOSE  43 1 

in  a  lateral  defect  are  likely  to  need  support,  cartilage  must  be  trans- 
planted between  the  skin  surfaces.  For  closing  these  defects  I  have 
used  folded  flaps  and  also  flaps  whose  under  surfaces  were  grafted, 
taken  from  distant  parts  and  from  the  neighborhood. 

In  perforating  wounds  of  the  bridge  of  the  nose  the  middle  turbinate 
may  be  detached  posteriorly,  and  (a  pedicle  being  left  in  front)  placed 
in  the  desired  position  and  sutured,  after  the  edges  have  been  freshened 
(Hett).  Both  bones  maybe  used  in  this  way  if  available.  The  sur- 
face is  covered  with  a  skin  flap  after  removal  of  the  exposed  mucous 
membrane  (Fig.  442). 

Recent  Fractures 

In  a  recent  case  of  nasal  fracture,  if  the  skin  is  broken,  the  splintered 
bones  should  be  molded  into  proper  position  by  means  of  a  long  Kelly 


I  2  3 

Fig.  442. — The  utilization  of  the  turbinates  and  the  septum  as  supports  (Hett). — 
I.  Method  of  advancement  of  the  inferior  and  middle  turbinates  for  purposes  of  support. 
2  and  3.  Septal  flaps  with  pedicle  above  or  below,  being  swung  forward  for  supporting  the 
bridge  of  the  nose. 

clamp  inserted  in  the  nares.  In  this  way  the  operator  can  see  the 
bones  and  if  necessary  can  suture  them  into  place.  The  bones  should 
be  supported  from  within  the  nares  on  each  side  by  means  of  a  long 
narrow  gauze  pack  saturated  with  a  thin  paste  of  bismuth  subnitrate 
and  castor  oil.  Gauze  saturated  with  the  bismuth  mixture  will  not 
stick  to  the  tissues;  it  remains  soft  and  prevents  infection.  The  skin 
wound  should  be  closed.  The  pack  should  be  removed  after  3  or  4 
days. 

If  the  skin  is  not  broken  the  same  procedure  is  carried  out,  except 
that  the  operator  cannot  see  the  bones  but  must  mold  them  into  shape 
between  the  clamp  within  and  the  fingers  outside. 

I  always  prefer  a  general  anesthetic  in  these  cases,  as  much  more 
effective  work  can  be  done.     Some  operators  use  metal  or  hard  rubber 


432 


PLASTIC    SURGERY 


splints  to  support  the  bones,  both  within  and  without,  but  my  prefer- 
ence is  for  the  gauze  pack  inside  and  a  paraffin  cast  outside. 


Old  Fractures 

External  lateral  deflection  of  the  nose  following  injury  is  often  very 
disfiguring  and  makes  a  deformity  that  should  be  corrected.  Mosher's 
or  Marshall's  operations  are  very  effective  (Fig.  443). 

Marshall's  Operation. — Make  a  very  small  incision  over  the  nasal 
process  of  the  superior  maxilla  near  its  base.  Introduce  a  narrow  chisel 
through  this  incision  and  divide  the  process  without  perforating  the 

nasal  mucous  membrane.  Carry 
out  the  same  procedure  on  the  other 
side.  Introduce  one  blade  of  a  heavy 
septal  forceps  into  the  nares,  the 
other  being  outside,  and  mobilize  the 
nasal  process  along  its  entire  length. 
Do  this  on  both  sides  and  then 
straighten  the  septum  with  the  same 
forceps.  If  necessary,  the  junction 
of  the  frontal  with  the  upper  end 
of  the  adjoining  nasal  bones  and 
processes  of  the  superior  maxillae 
may  be  fractured  with  a  mallet  strik- 
ing a  rubber  covered  lead  plate,  the 
blow  being  downward  and  against 
the  deflected  side.  These  bones  may 
also  be  loosened  with  a  chisel  through  the  incision.  The  nares  should 
be  packed  with  a  long  narrow  strip  of  gauze  soaked  in  the  bismuth  and 
castor  oil  mixture.  No  special  apparatus  is  applied  externally,  but 
cold  compresses  are  of  use  in  checking  the   swelling. 

I  have  obtained  good  results  by  simply  refracturing  the  nose  with 
a  mallet  striking  against  a  rubber  covered  lead  plate  or  a  padded  wooden 
block,  without  chiselling  the  bones,  then  straightening  it  with  septal 
forceps,  and  packing.  The  blow  should  be  against  the  convex  side. 
A  plaster  cast  may  be  useful  in  certain  cases. 


Fig.  443. — Operation  for  the  correc- 
tion of  lateral  deformity  of  the  nasal  bones 
following  fracture  (Mosher). — -The  line 
A  indicates  the  skin  incision  through 
which  the  bone  incisions  are  made  with  a 
chisel.  The  dotted  lines  show  the  bone 
incisions.  This  may  be  done  on  both 
sides  if  necessary. 


Rhynophyma  (Acne  Hypertrophica) 

For  the  distressing  deformities  of  the  nose  due  to  acnehy  pertrophica 
radical  surgical  measures  are  needed.     Place  the  finger  in  the  nostril 


SURGERY  OF  THE  EXTERNAL  NOSE 


433 


and  excise  the  entire  growth  down  to  the  cartilage.  Bleeding  although 
severe  can  be  easily  checked.  The  skin  at  the  nostril  margin  should  be 
conserved  as  far  as  possible  to  avoid  subsequent  contracture.  The 
defect  on  the  nose  may  either  be  allowed  to  heal  by  granulation  or, 
preferably,  be  grafted;  otherwise  sliding  flaps  from  the  cheeks  may  be 
used  to  cover  the  raw  surface.  Some  remove  the  growth  with  the 
cautery,  but  this  method  endangers  the  vitality  of  the  cartilage  and 
should  be  used  with  caution  (Fig.  444). 

In  addition  to  the  swelling  and  lobulation  rhynophyma,  I  have 
sometimes  seen  fissures  extending  through  the  cartilage  into  the  nose, 


Fig.  444. — Operation  for  rhinophyma  (Laurens). — i.  The  dark  line  indicates  the 
incision  made  for  the  removal  of  the  growth  on  one  side  of  the  nose.  2.  The  finger  is 
placed  in  the  nostril  and  the  growth  is  removed  down  to  the  cartilage.  The  raw  surface  is 
then  skin  grafted. 

between  large  pedunculated  tumors.  In  such  cases  the  operation 
becomes  somewhat  complicated.  The  tumors  should  be  completely 
excised  down  to  the  cartilage  and  the  fissured  edges  of  the  cartilage 
should  then  be  freshened  and  after  proper  trimming  should  be  closed. 


Angioma  of  the  Nose 

The  treatment  of  angioma  has  already  been  considered  in  the  Sec- 
tion on  Congenital  ^Malformations.  I  might  say,  however,  that  in  the 
rare  enormous  pulsating  angiomata  involving  the  nose,  it  may  be  neces- 
sary to  tie  off  the  external  carotid  on  one  or  both  sides;  the  temporal 
and  the  facial  arteries  and  veins  on  both  sides,  but  even  then  excision 

28 


434 


PLASTIC    SURGERY 


(which  is  the  method  of  choice),  is  difficult  and  dangerous  (Figs.  445- 

447)- 

RHINOPLASTIC  METHODS 

Three  general  methods  are  used  in  reconstructive  work  on  the  nose, 
in  all  of  which  the  blood  supply  of  the  transplanted  tissue  is  trans- 
mitted through  a  pedicle. 

I.  The  Indian  method  of  taking  a  flap  from  the  forehead  and 
bringing  it  into  place  by  twisting  the  pedicle.  The  pedicle  may  or 
may  not  be  divided  subsequently. 


Fig.  445. — Hemangioma  of  the  nose  and  forehead. — Photograph  taken  when  the 
patient  was  four  years  old.  Very  sUght  swelling  can  be  noted,  although  there  is  a  history 
of  bluish  discoloration  beneath  the  skin.  There  was  gradual  increase  in  the  size  of  the 
growth  until  two  years  before  her  admission,  when  more  rapid  growth  occurred.  On 
admission  the  huge  growth  pulsated,  and  a  loud  systolic  thrill  could  be  heard  over  the 
nose  and  on  the  forehead  as  far  out  as  the  temporal  regions.  Before  the  patient  came  under 
my  care  both  external  carotid  arteries  and  some  of  the  nasal  vesselghad  been  tied.  The 
only  result  was  the  disappearance  of  the  thrill.      (See  figures  446  and  447.) 


2.  The  French  method  of  sliding  flaps  from  adjacent  tissue, 
normally  without  twisting  the  pedicle.  The  pedicle  is  seldom  if  ever 
divided,  unless  a  secondary  shifting  is  necessaxy. 

3.  The  Italian  method  of  using  a  flap  from  the  arm,  or  other 
distant  part,  the  pedicle  being  severed  after  from  ten  days  to  two  weeks. 

Many  combinations  of  these  methods  have  been  devised,  and  in 
addition  skin  grafting  is  frequently  necessary.  All  of  the  operations 
to  be  described  have  been  modified  many  times,  but  the  principles 
have  remained  the  same. 

The  choice  of  method  depends  on  the  degree  of  destruction,  the 
dimensions  of  the  flap  required,  the  presence  or  absence  of  scar  in  the 


SURGERY  OF  THE  EXTERNAL  NOSE 


435 


Fig.  446. — Hemangioma  of  the  nose,  continued. — i.  2  and  3.  Photographs  taken  when 
the  patient  was  seventeen  years  old.  and  after  pulsation  had  ceased.  Note  the  extent  of 
the  growth  and  the  horrible  deformity.  Spontaneous  hemorrhages  were  frequent  and  on 
several  occasions  almost  exsanguinated  the  patient  before  the  bleeding  could  be  checked. 
Huge  blood  channels  were  found  on  operation  and  some  were  as  large  as  a  lead  pencil  and 
led  directly  through  into  the  skull.  Radium  was  used  without  benefit.  There  was  such 
marked  hemorrhage  during  any  operation  on  the  growth  that  an  attempt  was  made  to  form 
scar  tissue  through  the  growth  in  order  to  make  operative  procedure  possible.  This  was 
accomplished  by  the  injection  of  equal  parts  of  formalin,  glycerin  and  90  per  cent,  alcohol, 
as  advised  by  Morestin,  and  by  the  injection  of  boiling  water.  Multiple  punctures  with 
the  Pacquelin  cautery  were  also  tried.  Finally  sufficient  scar  tissue  was  produced  to  allow 
operative  interference  without  excessive  hemorrhage.  Then  gradual  partial  excision  was 
undertaken. 


Fig.  447. — Hemangioma  of  the  nose,  continued. — Shows  the  result  of  excisions  to  date. 
The  spontaneous  hemorrhages  have  ceased  and  the  condition  is  considerably  improved. 
Much  more  will  be  done  for  this  patient,  and  eventually  we  may  hope  for  a  nose  which  will 
not  be  especially  conspicuous. 


436  PLASTIC    SURGERY 

surrounding  skin,  the  age  and  condition  of  the  patient,  and  the  im- 
portance of  minimizing  the  scars  made  upon  the  face. 

It  must  be  emphasized  that,  in  cases  in  which  the  framework  of  the 
nose  has  been  destroyed,  it  is  useless  to  attempt  reconstruction  with 
either  single  or  double  (external  and  internal)  skin  flaps,  unless  these 
flaps  are  supported  by  a  framework. 

In  all  flap  operations  it  is  essential  to  calculate  the  size  and  shape 
of  the  flap  to  be  used  by  means  of  a  pattern  made  of  some  material 
which  is  flexible  and  can  be  sterilized.  For  this  purpose  thick 
rubber-dam  is  most  suitable.  The  flap  should  be  at  least  one-third 
larger  than  the  defect  it  is  to  cover. 

It  is  very  much  better  to  raise  a  flap  which  is  considerably  over- 
size than  one  which  is  too  small;  excess  tissue  can  always  be  removed. 
The  most  advantageous  position  of  the  pedicle  should  also  be  determined. 

Great  technical  difficulties  are  encountered  in  carrying  out  many  of 
the  reconstructive  operations  on  the  nose,  especially  in  handling  flaps 
with  broad  films  of  bone  attached.  Judging  from  the  diagrams  an 
inexperienced  worker  might  be  led  to  suppose  that  the  entire  process  is 
simple  and  may  be  completed  in  one  or  two  operations,  but  this  is  far 
from  the  fact.  In  many  instances  from  twenty  to  thirty  (mostly 
minor  operations),  are  necessary  before  the  desired  result  is  obtained. 
Obviously  it  is  difficult  to  avoid  infection  in  many  rhinoplastic  opera- 
tions, and  this  is  always  a  serious  complication. 

In  a  properly  cut  flap  from  the  forehead  the  blood  supply  is  perfect 
and  it  is  often  necessary  after  rotating  the  flap  to  tie  off  spurting  vessels 
in  the  tip  of  the  free  border.  Sensation  is  referred  to  the  forehead  until 
the  pedicle  is  cut. 

Before  reconstruction  of  the  nose  is  attempted,  care  must  be  taken 
to  remove  all  scar  tissue  which  obstructs  the  pyriform  opening 

It  is  often  advantageous  to  form  the  nostrils  and  build  the  nose 
over  nasal  splints  attached  either  to  a  band  around  the  forehead  or, 
better  still,  to  a  dental  plate.  This  apparatus  is  allowed  to  remain  in 
place  as  long  as  necessary  and  is  so  arranged  that  the  nostril  splints 
may  be  readily  removed  and  replaced. 

Anesthesia. — ^In  all  extensive  operations  a  general  anesthetic  should 
be  used.  Many  of  the  less  formidable  procedures  can  be  done  under 
local  anesthesia,  either  by  the  infiltration  method,  or  by  blocking. 

Preparation. — The  nose  and  throat  should  be  sprayed  with  Dobell's^ 
Boulton's,  Dichloramine-T,  or  some  other  antiseptic  solution,  every 
three  hours  for  several  days  before  operation. 


SURGERY  OF  THE  EXTERNAL  NOSE 


437. 


All  hair  is  shaved,  or  clipped  close  where  shaving  is  impossible. 
The  skin  is  cleansed  with  ether  or  benzin.     Crusts  are  removed.     The 


Fig.  448. — The  Indian  method. — Operation  for  restoration  of  complete  loss  of  nose. — 
I.  Outline  of  oval  flap.  Note  position  of  pedicle.  2.  Flap  turned  through  180  degrees, 
to  bring  it  into  position  with  skin  surface  outward.  Note  tip  of  flap  attached  to  upper  lip 
to  form  the  columna.  3.  Pedicle  severed  after  10  to  14  days.  The  pedicle  end  should  be 
turned  back  into  its  normal  position.  The  flap  end  should  be  utilized  on  the  bridge  of  the 
nose. 


Fig.  449.  Fig.  450. 

Fig.  449. — Operation  for  complete  loss  of  nose  (Lisfranc). — Note  the  shape  of  the 
flap.  The  incision  on  one  side  is  lower  than  the  other,  and  in  this  way  the  torsion  of  the 
pedicle  is  somewhat  lessened.  The  margins  around  the  nasal  defect  are  dissected  up,  and 
the  edges  of  the  flap  are  inserted  in  this  groove. 

Fig.  450. — Operation  for  complete  loss  of  nose  (v.  Graefe). — Note  the  rectangular  pro- 
jection at  the  upper  border  which  is  to  be  used  to  form  the  columna. 


exposed  mucous  surface  is  washed  with  salt  solution  and  dried.  Finally 
the  skin  and  mucous  membranes  are  painted  with  one-third  strength 
tincture  of  iodin. 


438 


PLASTIC    SURGERY 


Indian  Method 

The  use  of  the  forehead  flap  by  the  Indian  method  is  the  basis  on 
which  all  subsequent  improvements  in  rhinoplastic  operations  have 
been  made. 


Fig.  451.  Fig.  452. 

Pig.  451. — Operation  for  complete  loss  of  nose  (Petrali). — An  oval  flap  is  raised  and 
its  extremity  is  folded  on  itself  to  form  the  columna. 

Pig.  452. — Operation  for  complete  loss  of  nose  (Forgue). — The  flap  differs  in  shape  and 
the  pedicle  is  much  wider  than  in  the  usual  operation,  extending  from  the  middle  of  the 
eyebrow  to  the  midline  of  the  nasal  defect. 

The  pedicle  is  usually  located  between  the  inner  ends  of  the  eye- 
brows; it  should  be  from  2.  to  3.  cm.  {%  to  13^:5  inches)  wide  and  include 


Fig.  453.  Pig.  454- 

Pig.  453. — Operation  for  complete  loss  of  nose  (Delpech). — This  differs  from  the  Indian 

operation  only  in  the  trident  shape  of  the  free  extremity.      The  central  tongue  forms  the 

columna,  and  the  lateral  tags  line  the  alas. 

Fig.  454. — Operation  for  complete  loss  of  nose  {Landreaii) . — The  flap  is  transverse  and 

the  base  of  the  pedicle  is  upward.     A  flap  cut  in  this  way  eliminates  the  torsion. 

the  arteries  on  each  side  of  the  nose.     After  the  proper  pattern  has  been 
designed,  and  the  situation  from  which  the  flap  is  to  be  raised  has 


SURGERY  OF  THE  EXTERNAL  NOSE 


439 


been  selected,  the  outline  can  be  marked  out  with  nitrate  of  silver 
stick  the  day  before,  or  with  a  scalpel  at  the  time  of  operation,  along 
the  edges  of  the  pattern.  The  flap  in  the  original  Indian  operation 
was  oval  and  vertical,  and  was  twisted  i8o°  to  bring  it  into  position. 


Fig.  455.  Fig.  456. 

Fig.  455. — Operation  for  complete  loss  of  nose  (Langenbeck). — The  shape  of  the  superior 
border  of  the  flap  and  the  pedicle  is  curved,  the  left  lateral  incision  being  very  close  to  the 
nasal  defect. 

Fig.  456. — Operation  for  complete  loss  of  nose  (Labat-Dubowitzky) . — -Note  the  shape 
of  the  fiap  and  the  position  of  the  pedicle.  The  flaps  A  and  B  are  turned  under  to  line  the 
ala.      The  flap   C  is  folded  on  itself  longitudinally,   and   sutured   to   form   the  columna. 


Fig.  457.  Fig.  458. 

Fig.  457. — Operation  for  complete  loss  of  nose  {Alquie). — The  flap  is  transverse. 
The  pedicle  is  downward. 

Fig.  458. — Langenbeck's  second  operation  for  complete  loss  of  nose. — The  flap  is 
oblique.     The  skin  between  the  pedicle  and  the  nasal  defect  is  removed. 


Many  modifications  have  been  made  in  the  shape  and  direction 
(horizontal  or  oblique)  of  the  flap,  and  the  position  of  the  incisions  which 
mark  out  the  pedicle.  The  operation  is  usually  done  in  one,  but  it  may 
be  done  in  two  stages  (Linhart,  Szymanowski). 


440 


PLASTIC    SURGERY 


Diagrams  of  the  various  shapes  in  which  flaps  have  been  cut,  and  the 
position  of  the  pedicles  will  be  shown,  in  order  to  supply  suggestions 
which  may  be  of  use  in  selecting  the  type  of  flap  desired. 


Fig.  459.  Fig.  460. 

Fig.  459. — Operation  for  complete  loss  of  nose  (Labat). — Note  the  shape  of  the  flap, 
and  the  formation  of  the  pedicle.  This  lessens  the  torsion  of  the  pedicle,  and  the  small 
triangle  of  skin  at  the  root  of  the  nose  is  dissected  up,  and  turned  down  to  form  the  lining 
of  that  portion  of  the  frontal  flap. 

Fig.  460. — Operation  for  complete  loss  of  nose  (Auvert). — The  frontal  flap  is  made  at 
an  angle  of  45  degrees,  and  the  left  incision  forming  the  pedicle  enters  the  nose  defect  at  the 
midline. 


Fig.  461.  Fig.  462. 

Fig.  461. — Operation  for  complete  loss  of  nose  (Dieffenbach) . — The  flap  is  cut  wider  at 
its  upper  extremity  than  in  Lisfranc's  operation.  The  remains  of  the  nose  are  either  re- 
moved or  turned  inward  to  line  the  edges  of  the  frontal  flap.  The  rectangular  extremity 
of  the  flap  is  inserted  in  the  transverse  incision  just  below  the  nasal  defect. 

Fig.  462. — Operation  for  complete  loss  of  nose  {v.  Ammon). — This  operation  is  much 
the  same  as  that  of  Dieffenbach's,  except  that  the  shape  of  the  flap  is  different. 


For  the  reconstruction  of  the  nose  the  Indian  method  is  bad  in 
principle  and   the  results  are  poor.     It  is  not  possible  to  bridge  a 


SURGERY  OF  THE  EXTERNAL  NOSE 


441 


Fig.  463.  Fig.  464- 

Fig.  463. — Langenbeck's  third  operation  for  complete  loss  of  nose. — This  differs  in  the 
shape  of  the  flap,  and  in  the  incisions  forming  the  pedicle.  The  margins  of  the  nasal  defect 
may  either  be  removed  or  turned  in. 

Fig.  464. — Operation  for  complete  loss  of  nose  {Szymanowski) . — This  is  also  a  two- 
stage  operation.  Trace  and  raise  the  flap  DABC.  Then  make  the  incisions  FH  and  GL. 
This  forms  the  flaps  AFH  and  GLB,  which  are  turned  under  and  secured.  Fold  the  septum 
(columna)  flap  U  on  itself  lengthwise.  Return  the  flap  to  its  bed.  In  from  10  to  14  days 
freshen  the  edges  of  the  nasal  defect,  or  turn  them  in.  Raise  the  flap  and  suture  it  into 
position.  In  order  to  close  the  forehead  defect  the  incisions  M  X  and  OP  are  made,  and  if 
the  skin  is  lax  the  edges  OR  and  MQ  may  be  approximated. 


Fig.  465. — Operation  for  complete  loss  of  nose  (Labat-Blasius). — i.  The  outline  of  the 
frontal  flap  is  cut  with  the  exception  of  the  areas  between  AB,  CDEF  and  GH.  The  sides 
of  the  future  columna  AI  and  BK  are  incised.  Then  the  flaps  AIC  and  BKE  are  turned 
under  and  sutured  in  the  position  indicated  by  the  dotted  lines  CIM  and  EKM.  2.  After 
the  inturned  flaps  have  healed  (10  to  14  days),  the  entire  flap  is  raised,  the  portion  AB 
is  folded  lengthwise  on  itself,  and  the  flap  is  transplanted.  This  gives  a  lining  to  the  nostrils 
before  the  flap  is  shifted. 


442 


PLASTIC    SURGERY 


large  defect  with  an  unlined  flap  without  support  and  have  it  retain  any 

resemblance  to  a  nose  after  shrinkage  has  taken  place  (Fig.  448-467). 


Fig.  466. — Operation  for  complete  loss  of  nose  (Linhart). — This  operation  is  quite 
similar  to  the  Labat-Blasius  operation,  and  is  done  in  two  stages,  the  flap  being  turned 
under  in  the  same  manner.  The  advantage  is  that  the  oblique  incisions  form  the  alee, 
which  are  less  thick,  the  nostrils  are  not  so  narrow,  and  the  septum  (columna)  is  better 
formed. 


The  French  Method  (The  Method  of  Celsus) 

Sliding  flaps  from  adjacent  tissue  should  not  be  used  alone  in  total 
nose  reconstruction.     I  have  found  the  method  very  valuable  however 


Fig.  467. — Operation  for  complete  loss  of  nose  (Blasius). — This  double  lateral  frontal 
flap  operation  is  extremely  useful  at  times.  The  flaps  DCBA,  and  KGFWA,  are  dissected 
up,  and  turned  downward  and  inward,  so  that  skin  surface  is  outward.  P  is  in  the  midline 
to  form  the  columna.  N  is  sutured  to  the  base  of  P.  The  points  M  and  O  form  the  outer 
ends  of  the  alae. 


in  the  repair  of  smaller  defects,  and  when  used  in  conjunction  with  the 
other  methods,  in  forming  a  lining  for  the  defect  or  in  covering  the  raw 
surface  of  another  flap  (Fig.  468). 


SURGERY  OF  THE  EXTERNAL  NOSE 


443 


The  Italian  Method 

The  history  of  the  development  of  this  method  has  been  considered 
in  another  section.  A  pedunculated  flap  from  the  arm,  applied  with 
raw  surface  inward,  was  first  used  by  Tagliacozzi;  later  on  by  Fabrizi 
and  others,  the  forearm  was  utilized.  The  transfer  has  been  made  from 
the  chest,  or  abdomen,  to  the  forearm  (Steinthal),  and  then  to  the  nose. 
Another  modification  is  the  transfer  of  a  flap  from  the  breast  (in  women) 


I  -  3  4 

Fig.  468. — The  restoration  of  the  nose  by  the  use  of  cheek  flaps. — i  and  2.  The  con- 
dition of  the  nose  following  the  application  of  "cancer  paste."  Two  unsuccessful  attempts 
were  made  by  me  to  repair  this  defect  with  a  flap  from  the  arm.  3  and  4.  The  repair  was 
made  in  numerous  operations  by  the  use  of  flaps  from  the  cheeks  and  by  the  gradual  shifting 
of  these  tissues  with  skin  grafting,  so  that  the  defects  were  filled  with  lined  flaps.  Photo- 
graph taken  one  and  a  half  years  after  discharge  from  the  hospital.  A  forehead  flap  could 
have  been  used  in  this  case. 

directly  to  the  nose  (E.  Hollander) ;  from  the  shoulder  or  clavicular 
region  directly  to  the  nose  (^Mandry,  Aymard,  and  others). 

The  use  of  a  single  unlined  and  non-supported  flap,  transplanted 
by  this  method  is  not  advisable  for  the  reconstruction  of  a  total  loss  of 
nose,  but  in  the  reconstruction  after  partial  loss  it  is  invaluable  in 
selected  cases. 

Several  complicated  pieces  of  apparatus  for  holding  the  parts  in 
position  have  been  devised,  but  as  each  individual  dift'ers  in  size,  and  as 
the  desired  position  varies,  these  set  pieces  are  not  advisable,  although 
an  apparatus  may  be  specially  constructed  for  certain  cases. 

Numerous  methods  of  supporting  the  arm  have  been  suggested. 
Tn  my  own  experience  a  plaster-of-Paris  cast  has  been  the  most  satis- 
factory, although  its  proper  application  is  difficult  when  the  patient  is 


444 


PLASTIC    SURGERY 


Fig.  469.  Fig.  470.  Fig.  471. 

Methods  of  forming  flaps  from  the  arm  (after  Nelaion  and  Omtredanne) . 

Fig.  469. —  The  Method  of  Tagliacozzi. — The  flap  is  left  attached  at  both  ends,  being 
held  from  its  bed  by  rubber  protective.  The  upper  pedicle  is  severed  after  3  weeks,  and 
transplanted. 

Fig.  470. — The  Method  of  v.  Graefe. — The  flap  is  raised  and  transplanted  to  the  nose 
immediately.      The  pedicle  being  severed  from  the  arm  10  to  14  days  later. 

Fig.  471. —  The  Method  of  Dieffenbach. — i,  2  and  3.  Incisions  are  made  as  indicated 
by  the  solid  lines.  The  flap  is  raised  from  the  arm  but  is  left  attached  at  both  ends. 
It  is  then  folded  on  itself  lengthways,  and  sutured  to  the  free  edge  on  the  opposite  side. 
Then  after  several  weeks  the  upper  pedicle  is  cut,  the  double-faced  flap  is  opened,  and,  is 
sutured  to  the  freshened  nasal  margins.      Two  weeks  later  the  pedicle  on  the  arm  is  cut. 


Fig.  472. — Operation  for  the  reconstruction  of  the  nose  by  the  Italian  method  (Fabrizi). 
— A  triangular  flap  with  its  base  transverse  is  raised  from  the  anterior  outer  portion  of  the 
forearm.  It  is  sutured  into  the  freshened  edge  of  the  nasal  defect.  The  hand  is  placed 
on  the  opposite  shoulder  and  secured.  Two  weeks  later  the  pedicle  is  severed,  and  after 
several  days  the  nose  is  shaped. 


SURGERY  OF  THE  EXTERNAL  NOSE 


445 


Fig.  473. — Operation  for  the  reconstruction  of  the  nose  by  the  Italian  method,  with 
a  double  transfer  (Steinthal). — i  and  2.  A  flap  is  raised  from  the  chest  wall  and  its  free  ex- 
tremity is  sutured  into  an  incision  on  the  radial  ;ide  of  the  wrist.  After  two  weeks  the 
pedicle  is  severed,  and  the  free  end  is  immediately  sutured  into  the  freshened  nasal  defect. 
The  hand  rests  against  the  forehead.      Two  weeks  later  the  flap  is  cut  away  from  the  wrist. 


Fig.  474. — Operation  for  total  rhinoplasty  (£.  Hollander). — i.  Shows  the  outline  of  the 
flap  on  breast  and  chest.  The  base  is  just  above  the  areola,  the  free  end  is  upward.  2. 
The  breast  pushed  upward,  and  the  flap  in  position.  The  pedicle  is  severed  after  ten  to 
fourteen  days.  Any  desired  cartilaginous  supports  could  be  implanted  before  raising  the 
flap. 


446 


PLASTIC    SURGERY 


under  a  general  anesthetic.  In  cases  in  which  the  operation  is  done 
under  a  local  anesthetic,  the  application  of  the  cast  is  much  easier,  as 
the  patient  can  hold  the  arm  in  position  while  the  cast  is  being  applied. 
The  body  of  the  cast  may  be  prepared  and  fitted  on  before  operation, 
if  desired. 

In  using  plaster  of  Paris  great  care  should  be  taken  to  pad  the  parts 
sufficiently.  The  plaster  may  or  may  not  be  reinforced  with  metal 
strips  or  woven  wire.  The  cast  may  be  later  cut  away  to  the  minimum 
amount  necessary  for  support.  At  best  all  methods  are  uncomfortable, 
but  I  have  found  that  children,  after  the  first  day  or  two,  become  quite 
reconciled  to  the  enforced  position  necessary,  although  it  must  be 
confessed  that  the  whole  process  is  very  trying  to  all  concerned. 


Fig.   475. — Double  transfer  of  a  flap  from  the  chest  in  rhinoplasty  {A.  Rosenstein) . — - 

1.  The  flap  raised  from  the  chest  wall  with  pedicle  A,  in  the  clavicular  region.      The  free 
end  is  implanted  under  the  chin.      The  flap  should  be  longer  than  the  neck  to  avoid  tension. 

2.  The  pedicle  is  cut  and  the  free  end  implanted  in  nasal  defect.      Subsequently  the  pedicle 
is  cut  away  from  the  chin. 

I  often  remove  the  cast  after  a  few  days,  and  replace  it  with  rein- 
forced crinoline,  which  is  lighter.  There  is  a  certain  risk  of  embolism 
when  the  arm  is  set  free,  but  so  far  I  have  been  fortunate  enough  not 
to  encounter  this  accident. 

There  is  always  more  or  less  infection,  for  it  is  extremely  difficult 
to  keep  the  supporting  apparatus  clean,  and  it  soon  becomes  offensive. 
The  advantages  of  the  method  are  that  there  is  no  scarring  of  the  face 
and  that  normal  tissue  can  be  transplanted. 


The  Double -flap  Method 

After  failure  to  get  results  with  a  single  flap,  irrespective  of  the 
method  used,  the  next  advance  in  technic  was  in  the  use  of  a  double 
flap,  one  flap  with  the  skin  surface  inward  to  line  the  nose  and  another 


SURGERY  OF  THE  EXTERNAL  NOSE 


447 


Fig.  476.  t'lo.  477. 

Fig.  476. — Operation  for  the  reconstruction  of  the  nose  by  the  modified  Indian  method 
(Keegan). — The  flaps  CABD,  and  GEFH,  are  raised  and  turned  down.  (There  is  no 
necessity  of  having  a  space  between  these  flaps.)  Where  they  overlap.  Smith,  instead 
of  trimming  the  edges  (as  Keegan  does)  inserts  the  flap  as  a  scroll,  raw  surface  to  raw 
surface,  and  after  spHtting  the  old  septum  from  the  insertion  of  the  original  columna 
upward,  he  stitches  each  one  into  its  respective  side  of  the  split  septum,  and  brings  the 
raw  surfaces  together  with  a  few  sutures,  thus  forming  a  septum  as  well  as  a  lining  to  the 
nose.      The  forehead  flap  is  then  brought  down  and  fitted  as  usual. 

Fig.  477. — Operation  for  the  reconstruction  of  the  nose  by  the  modified  Indian  method 
(Thiersch). — The  flaps  A  and  B  with  base  adjacent  to  the  nasal  defect  are  raised,  reflected, 
and  sutured  together  in  the  midline,  epithelial  surface  downward.  Then  the  frontal  flap 
is  brought  down  to  cover  the  raw  surface.  The  nostrils  are  formed  and  the  skin  defects 
are  either  sutured  or  skin  grafted. 


Fig.  478. — Operation  for  the  reconstruction  of  the  nose  by  the  combined  Italian  and 
Indian  methods  (Kiister). —  i  and  2.  A  flap  is  raised  from  the  inner  anterior  portion  of  the 
arm  with  its  base  upward.  It  is  sutured  into  the  nasal  defect  with  skin  surface  inward. 
The  pedicle  is  severed  after  from  10  to  14  days,  and  the  raw  surface  is  covered  with  an 
anterior  flap  from  the  forehead  (or  with  a  skin  graft). 


448 


PLASTIC    SURGERY 


with  the  skin  surface  outward  to  cover  the  flap  first  appKed.  The 
reconstruction  of  a  total  loss  of  nose  by  this  method,  although  an 
improvement  on  the  single  flap,  is  also  unsatisfactory  without  the 
employment  of  a  proper  support. 


NANiY-^, 


Fig.  479. — Operation  for  the  reconstruction  of  the  nose  (Helferich). — i  and  2.  A  flap 
A  with  its  base  adjacent  to  the  loss  of  substance  is  raised  from  the  cheek  and  turned  over- 
skin  side  downward,  and  is  sutured  to  the  freshened  edge  of  the  nasal  defect  on  the  opposite 
side.  Care  is  taken  to  utilize  the  stump  of  the  ala.  Then  the  flap  B  with  its  pedicle  above 
is  raised,  and  shifted  to  cover  the  raw  surface  of  flap  A.  Two  weeks  later  the  lower  portion 
of  the  pedicle  of  the  internal  flap  is  cut,  and  is  sutured  to  the  freshened  stump  of  the  ala 
on  that  side.      The  cheek  wounds  are  grafted.      The  inserts  indicate  the  positions  of  the  flaps 

In  the  operations  devised  by  Keegan,  Thiersch,  Helferich,  Klister, 
and  Berger,  as  shown  in  the  diagrams,  we  have  the  best  of  the  methods 
for  the  formation  of  double  flaps(Fig.  476-481). 


Pig.   480. — Operation  for  the  reconstruction  of  the  nose  (Berger). — i  and  2.  A  flap  as 
outlined  is  raised,  turned  down,  and  sutured  to  the  freshened  border  of  the  nasal  defect. 

A  double  flap  may  also  be  made  by  turning  on  itself  a  flap  from  the 
arm.  After  union  of  the  raw  surfaces,  the  edges  are  freshened  and  the 
flap  is  implanted  into  the  defect.  This  method  will  be  illustrated  later 
in  an  operation  of  the  author's  for  the  repair  of  a  cheek  defect. 

The  flap  may  be  lined  with  skin  by  grafting  the  under  surface 


SURGERY  OF  THE  EXTERNAL  NOSE  449 

either  with  OlHer-Thiersch,  or  with  whole-thickness  grafts,  by  the 
open  or  by  the  buried  methods,  and  allowing  healing  and  shrinkage  to 
take  place  before  the  flap  is  transplanted. 

Reconstruction  of  the  Framework  of  the  Nose 

There  are  two  methods  of  making  a  framework  for  the  nose.  In 
one  we  make  use  of  inorganic  jnaterials,  which  may  he  removable,  or  may 
be  buried.  Prosthetic  apparatus  has  already  been  considered,  but  I 
might  again  say  that  the  use  of  buried  inorganic  supports  is  inadvisable. 
In  certain  instances  removable  supports  may  be  considered  advanta- 


\ 

Fig.  481. — Operation  for  the  reconstruction  of  the  nose,  conlinued. — A  flap  with  its 
pedicle  toward  the  elbow  is  raised  from  the  anterior  surface  of  the  arm,  and  is  sutured  into 
the  forehead  defect,  and  covers  the  raw  surface  of  the  turned  down  flap.  The  arm  is 
secured,  and  after  lo  to  14  days  the  pedicle  is  cut  and  the  nose  is  shaped. 

geous  where  there  is  a  curtain  of  skin  which  covers  the  defect,  but  as 
a  general  rule  the  framework  of  the  nose  should  be  made  of  organic 
material. 

In  the  second  we  make  use  of  organic  materials.  Periosteum  alone 
included  in  the  flap  from  the  forehead  (Oilier,  1864)  for  the  formation 
of  a  framework  is  said  to  be  satisfactory  in  certain  cases,  as  bone  may 
be  formed  (if  bone  spicules  are  detached  with  the  periosteum),  but 
when  transplanted  free,  my  experience,  experimental  as  well  as  clinical, 
has  been  that  bone  is  never  formed  and  that  consequently  periosteum 
is  of  little  use  in  the  formation  of  a  support. 

29 


450  PLASTIC    SURGERY 

Bone  and  Cartilage. — The  bone  may  be  obtained  from  the  frontal 
region,  the  ribs,  tibia,  or  clavicle.  The  bone  transplant  may  be  sepa- 
rated from  the  underlying  bone  without  being  detached  from  the  over- 
lying soft  parts.  This  is  the  safest  method.  The  transplant  may  be 
free,  but  my  experience  has  been  that  a  free  bone  transplant  in  soft 
parts  will  eventually  be  absorbed  and,  when  in  contact  with  bone  at 
only  one  end,  it  will  eventually  atrophy. 

Cartilage  may  sometimes  be  obtained  by  submucous  resection  of  a 
portion  of  the  septum,  but  is  usually  secured  from  the  cartilaginous  ribs 
and  is  always  transplanted  free.  This  material  is  best  for  the  purpose 
and  it  will  be  noticed,  in  following  certain  operators'  work  that  those 
who  begin  with  the  use  of  bone  will  eventually  turn  to  cartilage  as  the 
best  material  for  the  construction  of  a  framework  for  the  nose. 

Cartilage  should  be  suitably  shaped  and  lateral  supports  properly 
placed.  It  may  be  implanted  between  the  layers  of  a  double  flap,  by 
burrowing,  after  the  flap  has  been  sutured  into  position  and  has  healed; 
it  may  be  placed  between  the  flaps  at  the  time  of  their  transplantation; 
or  better  still,  the  cartilage  may  be  inserted  in  the  desired  position  under 
the  proposed  lining  or  covering  flap,  until  it  is  established,  and  then 
transplanted  with  the  flap. 

Transplantation  in  Children. — The  advisability  of  transplanting 
bone  or  cartilage  as  a  nasal  support  in  children  is  still  undetermined. 
After  considerable  experience  with  bone  and  cartilage  transplants  in 
rhinoplasty,  my  conclusion  is  that  these  transplants  do  not  grow  in 
length,  in  fact  the  tendency  of  the  bone  is  to  shorten,  and  the  cartilage 
remains  its  original  length.  As  the  child  grows  the  new  nasal  support 
itself  will  not  increase,  although  it  may  apparently  do  so,  at  an  equal 
rate  with  the  bones  on  which  it  impinges. 

The  question  arises,  should  one  wait  until  full  growth  has  taken 
place,  or  should  the  operation  be  done  early?  My  own  opinion  is  that 
the  support  should  be  inserted  quite  early,  to  prevent  as  far  as  possible 
shrinkage  of  the  skin,  but  there  should  be  slight  over-correction.  Then, 
if  conditions  demand  further  work  after  the  growth  is  complete,  we 
have  a  better  chance  of  permanent  success,  as  the  skin  is  already 
stretched.  This  applies  especially  to  those  cases  of  congenital  lues  with 
saddle  nose,  or  to  early  flattening  of  the  nasal  bones  from  trauma. 

Rhinoplasty  with  Osteo-periosteal  Support 

The  operations  for  the  construction  of  a  nose  by  means  of  a  flap 
from  the  forehead  including  a  piece  of  the  underlying  bone  with  its 
periosteum,  was  devised  by  Konig,  in  1886.     Since  that  time  a  number 


SURGERY  OF  THE  EXTERNAL  XOSE 


451 


of  modifications  have  been  made  in  carrying  out  the  method.     Those 
by  Heh'erich,  Schimmelbusch.  and  Lexer,  being  among  the  best. 


Fig.  482. — Operation  for  the  reconstruction  of  the  nose  (Konig). — A  flap  i  cm.  (25  inch) 
wide  consisting  of  skin  and  a  thin  layer  of  bone  with  its  periosteum  is  raised  from  the  mid- 
line of  the  forehead.  Its  pedicle  is  at  the  root  of  the  nose,  and  its  free  end  extends  into  the 
hairline.  The  flap  is  turned  down,  skin  surface  inside,  the  bone  is  fractured  at  the  point 
to  be  the  tip,  and  the  end  of  the  flap  is  bent  inward,  and  the  extremity  is  sutured  to  the 
upper  lip.  The  skin  surrounding  the  nasal  defect  is  dissected  up  toward  the  midline,  and 
turned  in  and  sutured  to  the  median  flap.  An  obliquely  planned  pedunculated  flap  without 
periosteum,  is  raised  from  either  side  of  the  forehead,  and  is  twisted  to  cover  the  raw  sur- 
faces of  the  flaps  turned  in  to  line  the  nose.  Several  secondary  trimming  and  shaping 
operations  are  necessary. 


Fig.  483. — Operation  for  the  reconstruction  of  the  nose  (Schhnitulbusch). —  i  and  2. 
A  triangular  flap  of  skin,  periosteum  and  bone  is  raised  from  the  forehead.  The  pedicle 
which  is  3  cm.  (i  I5  inch)  wide,  is  between  the  eyebrows  and  the  base.  6  to  9  cm.  (2%  to  3^-^ 
inches)  wide,  is  near  the  hairline.  The  bone  is  raised  in  one  sheet  if  possible.  The  fore- 
head defect  is  then  closed  by  large  sliding  flaps  whose  upper  borders  follow  the  hairline. 
The  flap  is  allowed  to  granulate  and  is  then  grafted  (immediate  grafting  is  preferable). 
Then,  after  healing  is  complete,  the  bone  is  sawed  into  halves  through  its  grafted  surface. 
The  flap  is  turned  over,  grafted  side  in,  and  sutured  to  the  freshened  edges  of  the  nasal 
defect.  The  columna  can  be  planned  for  in  cutting  the  forehead  flap,  but  otherwise  can  be 
made  of  two  flaps  of  skin  from  the  margins  of  the  pyriform  opening,  as  shown  in  the  diagram. 

Israel  described  an  operation  in  which  a  flap  raised  from  the  forearm 
included  a  piece  of  the  ulna  for  support.  Gustav  ^Mandry  uses  a  flap 
which  includes  a  strip  of  bone  from  the  sternal  end  of  the  clavicle. 


452 


PLASTIC    SURGERY 


Free  bone  has  also  been  transplanted  between  the  surfaces  of  a 
double  faced  flap,  but  this  is  never  as  satisfactory  as  when  the  bone 
has  not  been  separated  from  its  overlying  soft  parts. 


ABC 
Pig.  484. — Lexer's  operation  for  the  restoration  of  total  loss  of  the  nose  (Binnie). — 
Remove  all  scar  obstructing  the  pyriform  opening  and  cover  the  raw  surface  with  flaps 
from  adjacent  skin,  being  sure  not  to  use  that  just  above  the  opening.  A  broad  skin 
osteoperiosteal  flap  is  raised  from  the  upper  half  of  the  forehead  and  is  turned  down  to  be 
covered  by  the  lower  portion  of  the  flap  which  contains  no  bone  (Fig.  484B).  Cover  the 
forehead  wound  with  Ollier-Thiersch  or  whole-thickness  grafts  (Fig.  484C). 


Rhinoplasty  with  a  Cartilaginous  Support 

Von  Mangold,  in  1899,  first  used  a  piece  of  costal  cartilage  for  a 
supporting  framework,  and  since  that  time  much  use  has  been  made  of 
free  grafts  of  costal  cartilage. 


y  y  /  y^j 


A  B 

Fig.  485. — Lexer's  operation  for  the  restoration  of  total  loss  of  the  nose,  continued. — 
Three  to  four  weeks  later  the  incisions  which  outline  the  pedicle  are  gradually  lengthened 
a  little  at  a  time,  until  the  inner  angle  of  the  eye  is  reached  on  one  side,  and  the  nasal 
opening  on  the  other  (Pig.  485 A).  Through  the  latter  incision  separate  the  skin  from 
the  root  of  the  nose  until  the  midline  is  reached,  and  it  becomes  possible  to  twist  the  pedicle 
into  position  without  tension.  From  the  under  surface  of  the  flap  raise  a  narrow  skin  flap 
to  form  the  columna,  and  through  the  same  incision  divide  the  bone  longitudinally  and  fold 
it  like  a  roof  (Pig.  485B).  Freshen  the  edges  of  the  nasal  defect  and  suture  the  flap  into 
position. 

The  cartilage  may  be  implanted  in  the  proposed  frontal  flap,  above 
or  below  the  periosteum,  and  allowed  to  remain  for  several  weeks  before 


SURGERY  OF  THE  EXTERNAL  NOSE 


453 


the  flap  is  raised.  Ordinarily  quite  a  narrow  piece  is  implanted,  but 
one  or  more  wide  pieces  shaped  as  desired  may  be  inserted  with  ad- 
vantage.    Cartilage  may  be  inserted  in  any  desired  position  into  a  flap 


Fig.  486. 


A  B  C 

Fig.  487. 
Figs.  486  and  487. — Lexer's  operation  for  the  restoration  of  total  loss  of  nose,  con- 
tinued. — After  several  weeks  (the  longer  the  better)  the  pedicle  is  divided  and  is  used  to  fill 
in  the  defect  between  the  brows.  A  number  of  weeks  later  begin  the  numerous  shaping  and 
trimming  operations  which  will  be  necessary-  to  bring  the  flap  into  the  resemblance  of  a 
nose.  To  form  a  depression  between  the  forehead  and  the  nose  excise  the  scars  on  each  side 
in  front  of  the  angles  of  the  eyes  down  to  the  bone,  and  remove  all  excessive  subcutaneous 
tissue.  If  the  skin  is  too  loose  after  this,  remove  a  sufficient  amount  from  the  edges  so  that 
it  will  fit  quite  snugly  to  the  bone  and  suture  the  edges  (Fig.  486B).  To  form  the  point 
of  the  nose  make  the  semilunar  incision  (Fig  487A).  Raise  the  skin  from  the  underlying' 
bone  with  an  elevator  and  insert  a  shaped  piece  of  bone  (periosteum  toward  the  skin) 
between  it  and  the  skin  as  shown  in  Fig.  486C  and  Fig.  487B.  The  insertion  of  the  bone 
causes  the  semilunar  incision  to  gape  and  this  is  allowed  to  granulate.  Subsequent  opera- 
tions are  necessary  for  the  formation  of  the  alae  (Fig.  486 D).  The  ultimate  result  is  said 
to  be  good.  I  have  never  employed  this  method,  but  have  cited  it  to  give  an  idea  of  the 
extreme  slowness  with  which  it  is  sometimes  necessary  to  proceed. 

which  has  been  folded  on  itself  and  will  Uve,  as  I  have  demonstrated 
experimentally.  ^ 

In  partial  loss  of  the  nose  the  methods  already  described  are  used 
with  modifications  to  meet  the  particular  case.     It  must  always  be 

'Davis,  J.  S.:  Johns  Hopkins  Hospital  BulL.  April.  1913,  116. 


454 


PLASTIC    SURGERY 


borne  in  mind  that   the  double-faced  flap  with  the  proper  support  is 
necessary  for  ultimate  success. 

I  have  in  mind  a  case  of  luetic  destruction  requiring  reconstruction 
of  the  lower  third  of  the  nose.  Many  attempts  had  been  made  to  re- 
construct this  portion,  but  with  little  success.  Finally  I  transplanted 
a  piece  of  costal  cartilage  extending  from  the  frontal  bone  to  the  lowest 
portion  of  the  tip  of  the  nose.  Later,  flaps  were  turned  down  from  the 
skin  on  the  bridge  ('as  described  in  Smith's  modification  of  Keegan's 


Fig.  488. — Operation  for  the  reconstruction  of  the  nose  {Israel). — i  and  2.  The  dark 
lines  outline  the  skin  flap  from  the  ulna  side  of  the  forearm.  The  skin  is  dissected  up 
exposing  the  ulna,  and  a  strip  of  bone  0.8  cm.  X  6.  cm.  ■(^••3  X  2%  inches)  is  raised  with 
the  skin,  except  at  the  upper  end  where  it  is  only  partially  sawed  through.  The  skin- 
periosteal  bone  flap  is  bent  up  and  protected.  Nine  days  later  the  bone  connection  is 
severed.  The  nose  is  modelled  as  well  as  possible  on  the  forearm,  and  the  surfaces  are 
allowed  to  grow  together.  Twelve  days  later  the  newly  modelled  nose  is  separated  from 
adhesions  on  the  arm,  and  protected  from  further  adhesions  by  dressings.  Five  days  later 
the  margins  of  the  nasal  defect  are  trimmed,  and  the  edges  are  turned  in  to  line  the  new  nose. 
The  pedicle  on  the  arm  is  lengthened  and  widened,  and  the  new  nose  is  sutured  to  the  nasal 
defect. 


methodj  to  line  the  nose  and  form  a  septum,  and  a  flap  from  the  fore- 
head was  brought  down  over  the  whole,  and  sutured  into  place,  care 
being  taken  to  form  the  columna  by  lengthwise  folding  of  the  tip  cut 
for  this  purpose. 

The  support  given  to  the  nose  by  a  strip  of  cartilage  (or  bone)  which 
impinges  on  the  frontal  bone  and  projects  beyond  the  nasal  bones  on 
the  "diving  board"  principle,  is  often  insufficient.     In  order  to  over- 


SURGERY  OF  THE  EXTERNAL  NOSE 


455 


Fig.  489. — Mandry's  operation  for  reconstruction  of  the  nose  (Beck). — i.  A  large  flap 
with^its  base  on  the  shoulder  and  its  free  end  over  the  sternoclavicular  articulation  is  marked 
out.  Then  the  skin  is  dissected  above  and  below  to  the  sternal  end  of  the  clavicle,  and  a 
piece  of  bone  AA',  4.5  X  0.5  cm.  (1:^5  X  ^i  inches)  is  raised  with  the  overlying  skin.  A 
flap  of  skin  CDD'C  is  raised,  its  base  being  on  the  line  CC,  and  is  folded  under  and  covers 
the  bone  on  both  sides  with  full  thickness  skin.  The  defect  is  closed.  The  flap  is  allowed 
to  drop  back  into  its  bed.  2.  Four  days  later  the  flap  is  raised  throughout  its  length,  the 
nasal  margins  are  freshened  and  the  flap  is  sutured  in  position.  One  week  later  the  pedicle, 
is  severed,  and  the  nose  is  shaped  in  due  time.  The  criticism  of  the  operation  is  that  in  a 
flap  of  this  length  the  cutting  of  a  window  of  skin  will  jeopardize  the  blood  supply,  and  this 
will  also  happen  if  the  second  and  third  operations  are  performed  too  soon. 


Fig.  490. — Operation  for  the  reconstruction  of  the  nose  with  cartilaginous  support 
(modified  from  Nelalon  and  Omhredanne). — i.  Outline  of  incisions  for  the  formation  of 
the  flap,  and  around  the  nose  defect.  The  dotted  line  indicates  the  position  of  the 
implanted  rib  cartilage.  2.  Flaps  of  skin  around  the  defect  are  turned  in  and  sutured 
together  to  line  the  nose.      Note  the  cartilage  in  position  under  the  forehead  flap. 


4S6 


PLASTIC    SURGERY 


come  this,  it  is  necessary  to  have  a  support  for  the  central  piece.  This 
may  be  done  by  double  or  single  lateral  supports,  which  hold  the  ridge 
in  place  (Aymard,  and  others).  These  may  all  be  implanted  in  the  flap 
before  it  is  raised,  or  may  be  inserted  subsequently  (Fig.  492). 


Fig.  491. — Operation  for  the  reconstruction  of  the  nose  with  cartilaginous  support, 
continued. — i.  The  forehead  flap  is  raised  and  its  free  end  is  infolded  to  line  the  alae. 
2.   The  flap  is  sutured  into  the  nasal  defect. 

The  columna  may  be  incised,  and  the  cartilage  (or  bone)  inserted 
in  such  a  way  that  one  end  rests  in  a  hole  made  in  the  superior  maxilla 
in  the  midline,  and  the  other  supports  the  newly  formed  bridge.  This 
is,  of  course,  possible  only  when  there  is  a  septum.     Another  method  is 


Fig.  492. — Rhinoplasty  with  a  compound  flap  from  the  shoulder  (Aytnard). — a.  The 
cartilage  implanted  under  skin  of  shoulder,  i.  The  longitudinal  piece  to  be  the  bridge. 
2  and  3.  The  transverse  pieces  under  i,  to  act  as  lateral  supports,  b.  The  flap  separated 
except  at  its  base  and  extremity,  infolded  and  sutured  skin  to  skin.  c.  The  flap  with  carti- 
lage in  position  on  the  nose.  The  pedicle  is  cut  in  due  time  and  the  body  of 'the  flap  is 
then  opened  and  fitted  into  its  original  bed. 

to  implant  two  pieces  of  cartilage  of  sufficient  length  side  by  side  in  a 
pocket  burrowed  under  the  mucous  membrane  of  the  floor  of  the  nose. 
After  a  sufficient  interval  (from  four  to  six  weeks)  the  muco-cartilagi- 
nous  flap  is  raised,  pedicle  in  front,  and  is  folded  on  itself;  the  edges  are 


SURGERY  OF  THE  EXTERNAL  NOSE 


457 


1^3  4 

Fig.  493. — The  restoration  of  a  nose  by  the  use  of  a  pedunculated  flap  from  the  fore- 
head.— I  and  2.  Side  and  front  views  before  operation.  The  patient  had  been  operated  on 
several  times  before  coming  under  my  care.  Bone  had  been  inserted  in  one  of  these  opera- 
tions and  was  utilized  later.  3.  Flaps  from  the  skin  of  the  nose  were  turned  down  and 
were  folded  in  to  line  the  forehead  flap,  and  also  to  form  the  septum  by  the  modified  Keegan 
method  suggested  by  Smith.  The  bone  which  had  been  implanted  was  also  shifted  down- 
ward. Then  a  pedunculated  flap  from  the  forehead  was  turned  down  and  sutured  into 
position,  the  columna  being  shaped  and  inserted  into  its  proper  position.  The  area  on  the 
forehead  was  grafted.  Note  the  horsehair  sutures  and  the  tubes  in  the  nostrils.  Photo- 
graph taken  five  days  after  operation.  4.  Taken  four  months  after  operation.  The 
pedicle  has  been  cut  and  several  minor  shaping  operations  have  been  done. 


Fig.  494 
continued. —  i 
operation. 


I  23  4 

— Restoration  of  a  nose  by  the  use  of  a  pedunculated  flap  from  the  forehead, 
and  2.  Taken  three  months  after  operation.     3  and  4.   Taken  six  months  after 


4.-8 


PLASTIC    SURGERY 


12  3  4 

Fig.  495- — The  restoration  of  a  nose  by  the  use  of  a  flap  from  the  forehead. — i  and  2. 
The  tissues  had  been  infiltrated  with  paraffin  and  treated  by  many  methods,  pedunculated 
flaps,  etc.,  before  admission,  and  the  nose  consisted  of  a  fiat  mass  of  scar  tissue  with  little 
or  no  resemblance  to  the  normal  organ.  3.  A  piece  of  cartilaginous  rib  was  inserted  into 
the  mass  of  scar  and  healed  nicely.  Then  the  pyriform  opening  was  trimmed  out  and  flaps 
from  the  nose  were  turned  down  to  line  the  forehead  flap  by  a  method  similar  to  that  de- 
scribed by  Keegan.  Then  the  upper  portion  of  the  nose  was  denuded,  the  flap  was  turned 
down  and  sutured  into  position,  and  the  forehead  wound  was  grafted.  Photograph  taken 
one  week  after  turning  down  the  flap.  The  tubes  in  the  nostrils  can  be  seen  and  also  the 
horsehair  sutures.  4.  Taken  five  weeks  after  operation.  The  pedicle  has  been  cut  and 
fitted  into  position. 


Fig.  496. — Restoration  of  the  nose,  continued. — i  and  2.  Taken  two  and  a  half  months 
after  operation.  Note  the  well  formed  columna.  Several  minor  shaping  operations  were 
done  to  lower  the  alae.     3.   Taken  nine  months  after  operation. 


SURGERY  OF  THE  EXTERNAL  NOSE  459 

sutured,  and  the  free  end  is  attached  to  the  under  surface  of  the  new 
nose. 

SADDLE  NOSE 

Alteration  in  the  shape  of  the  nose  depends  on  the  extent  of  destruc- 
tion of  the  bony  and  cartilaginous  framework,  consequently  there  are 
marked  variations  in  this  deformity. 

Three  types  may  be  noted:  (i)  Flattening  of  the  bridge  of  the  nose, 
without  destruction  of  tissue.  This  type  is  congenital,  or  follows 
trauma. 

(2)  The  loss  of  tissue  is  chiefly  in  the  cartilage,  the  bones  being 
intact,  as  a  consequence  of  injury  or  disease. 

(3)  The  cartilage  and  bone  are  both  destroyed,  usually  as  a 
result  of  disease,  sometimes  of  trauma. 

Following  severe  destruction,  in  addition  to  depression  of  the  bridge, 
there  is  a  tilting  up  of  the  tip  of  the  nose  which  makes  the  nostrils 
point  directly  forward. 

The  treatment  depends  on  the  amount  of  depression  of  the  bridge, 
and  the  degree  of  tilting,  the  movability  and  normal  condition  of  the 
skin,  and  the  amount  of  skin  contracture.  If  the  nose  is  markedly 
tilted  up  and  there  is  much  scar  tissue,  the  nasal  cavity  usually  has  to 
be  opened  in  order  to  correct  the  deformity.  If  the  tip  is  not  markedly 
tilted  up,  and  the  skin  is  in  good  condition,  the  correction  can  ordinarily 
be  made  without  opening  into  the  nasal  cavity. 

Prosthetic  injection  of  paraf^n  is  often  used  to  remedy  these  de- 
formities and  gives  immediate  results  in  cases  in  which  the  skin  is  lax. 
Considering  the  horrible  complications  which  sometimes  follow  the  use 
of  paraffin  in  spite  of  its  simplicity,  I  have  never  felt  justified  in  using  it. 

Various  inorganic  materials  have  been  implanted  to  raise  the  bridge 
but  the  same  objection  to  burying  inorganic  supports  holds  here  as 
elsewhere. 

Numerous  operations  have  been  devised  for  the  correction  of  saddle 
nose,  but  I  will  only  mention  those  which  I  have  found  useful,  and  one 
or  the  other  of  which  may  be  employed  in  the  correction  of  cases 
ordinarily  seen. 

Cartilage  Implantation  for  Raising  the  Bridge 

The  method  which  has  given  me  the  greatest  satisfaction  is  that 
originated  by  von  Mangold.     The  insertion  of  a  piece  of  rib  cartilage 


460 


PLASTIC    SURGERY 


to  form  the  new  bridge  can  either  be  done  externally  through  an  in- 
cision between  the  eyebrows,  or  across  the  bridge  of  the  nose,  or  inter- 
nally along  the  muco-cutaneous  margin,  just  inside  the  nostril.  The 
latter  incision  avoids  an  external  scar,  but  I  prefer  not  to  take  the 
greatly  increased  chance  of  infection  which  the  internal  incision  gives. 
The  external  scar  can  be  made  very  inconspicuous  and  the  greater 

safety  of  the  external  incision  (in  addition  to 
the  better  control  of  the  transplant),  makes 
its  use  desirable. 

My  method  of  procedure  probably  differs 
little  from  that  of  many  others.  A  short 
transverse,  or  slightly  curved  incision,  is  made 
at  the  root  of  the  nose,  with  its  convexity 
toward  the  tip,  and  the  soft  parts  are  divided 
down  to  the  periosteum.  A  silk  suture  is 
placed  in  each  lip  of  the  wound  for  retraction. 
The  periosteum  is  incised  transversely  and  is 
undermined  in  the  midline  until  the  naso- 
frontal junction  is  reached.  With  a  pair  of 
Mayo  scissors  a  tunnel  is  made  between  the 
skin  and  mucous  membrane,  from  the  trans- 
verse incision  to  the  tip  of  the  nose  (or  so 
far  as  it  is  desired  to  have  the  graft  extend), 
care  being  taken  not  to  open  into  the  nasal 
cavity.  Lateral  adhesions  should  be  divided 
subcutaneously  through  the  same  incision,  and 
the  nose  loosened  so  that  the  tip  may  be 
lowered.  Measurement  is  then  taken  of  the 
maximum  length  of  cartilage  required,  and 
pressure  is  applied  to  control  bleeding.  The 
cartilage  is  secured  from  the  cartilaginous  rib 
as  has  been  previously  described  (fresh  gloves  and  instruments  being 
used)  and  the  wound  is  closed,  care  having  been  taken  to  check  the 
hemorrhage  and  to  eliminate  all  dead  spaces.  The  cartilage  to  be 
inserted  must  be  shaped  to  fill  out  the  depression  that  it  is  meant  to 
correct,  and  this  can  be  done  by  means  of  a  pattern,  or  by  freehand 
trimming  after  several  trials  at  placing  it  in  position.  As  there  is  a 
tendency  for  the  cartilage  to  bend  somewhat  when  it  is  cut,  this  must 
be  taken  into  consideration,  and  a  straight  piece  be  used,  otherwise, 
although  the  bridge  may  be  raised,  the  tip  of  the  nose  may  be  deflected 


I 


Fig.  497. — Saddle  nose 
due  to  trauma.  Duration 
two  years. — i.  Before  opera- 
tion. 2.  Two  years  after  the 
implantation  of  a  free  graft 
of  cartilaginous  rib.  No 
shrinkage  has  occurred. 


SURGERY  OF  THE  EXTERNAL  NOSE 


461 


to  one  side  or  the  other.  I  usually  endeavor  to  retain  the  perichondrium 
on  one  side  of  the  transplant  and  try  to  place  this  side  under  the  skin 
if  it  is  convenient  to  do  so.     Nevertheless,  I  have  had  good  results  when 


123  4 

Fig.  498. — Saddle  nose,  probably  due  to  congenital  lues. — i  and  2.  Before  the  implanta- 
tion of  a  free  cartilaginous  graft.  3  and  4.  Three  months  after  operation.  By  massage 
the  tip  of  the  nose  is  being  gradually  lowered  and  the  adjacent  skin  stretched  during  the 
eighteen  months  since  operation,  so  that  with  further  minor  operative  procedures  a  good 
result  will  be  obtained.  In  a  case  of  this  type  opening  into  the  nasal  cavity  is  often  nec- 
essary in  order  to  lower  the  tip  of  the  nose. 


Fig.  499. — Saddle  nose  due  to  lues.  Duration  several  years. — i  and  2.  Front  and  pro- 
file view  before  operation.  3  and  4.  Front  and  profile  view  two  weeks  after  the  implanta- 
tion of  a  free  graft  of  cartilaginous  rib.  Note  the  position  of  the  scar  and  the  improvement 
in  appearance.      5.  The  result  nineteen  months  after  operation. 

the  perichondrium  is  away  from  the  skin,  as  well  as  with  the  cartilage 
completely  stripped. 

When  the  tip  of  the  nose  does  not  need  depressing,  the  cartilage 
is  simply  placed  in  the  channel  prepared  for  it.     The  cartilage  may 


46i 


PLASTIC    SURGERY 


be  left  quite  thick  at-  the  point  of  greatest  depression,  or  it  may  be 
reinforced  by  shorter  pieces  secured  beneath  it. 

When  we  desire  to  depress  the  end  of  the  nose,  the  tunnel  having 
been  made  to  the  tip,  the  cartilage  is  bent  and  is  sprung  into  the  channel 
prepared  for  it,  impinging  against  the  frontal  bone  and  extending  to 
the  tip  of  the  nose.  It  is  secured  from  lateral  slipping  with  two  or 
three  sutures  of  fine  catgut,  and  the  skin  is  closed  with  on-end  mattress 
sutures  of  horsehair. 


1234  5 

Fig.  500. — Saddle  nose  following  lues.  (Surg.  No.  44327).  i  and  2.  The  remaining  por- 
tion of  the  nose  is  retracted  almost  to  the  level  with  the  cheeks.  Note  the  scant  amount  of 
skin,  and  also  the  length  and  prominence  of  the  lip.  The  white  spot  in  the  center  of  the 
floor  of  the  nose  is  a  misplaced  normal  tooth.  3,  4  and  5.  The  appearance  of  the  nose  after 
the  implantation  of  a  piece  of  cartilage  to  bring  out  the  bridge,  and  also  pieces  to  hold  out 
the  alee.  Infection  occurred  on  the  left  side  of  the  nose  and  a  portion  of  the  cartilage 
supporting  the  ala  on  that  side  was  lost.  The  septum  was  formed  from  flaps  taken  from 
the  upper  lip  by  the  method  shown  in  Pig.  529. 

A  cast  made  of  one  of  the  flexible  paraffin  mixtures  and  replaced 
every  24  hours  during  the  first  week,  is  an  excellent  dressing,  and 
minimizes  the  scar. 

I  have  used  free  cartilage  transplants  in  a  number  of  instances, 
and  find  them  most  satisfactory.  Sometimes  the  spring  of  the  cartilage 
causes  the  skin  on  the  tip  of  the  nose  to  become  thin  at  the  point 
of  pressure,  but  this  area  may  be  removed  and  the  cartilage  shortened 
slightly,  without  interfering  with  the  result  (Fig.  497-500). 

Where  the  skin  is  contracted  the  tension  may  be  relieved  by  making 
an  inverted  V-shaped  incision,  the  point  of  which  is  just  above  the 
cartilage,  and  then  pushing  the  skin  down  and  suturing  it  in  the  shape 
of  a  Y. 


SURGERY  OF  THE  EXTERNAL  XOSE  463 

Instead  of  using  a  single  piece  of  cartilage,  One  may  be  inserted  on 
each  side.  Again,  pieces  may  be  inserted  to  support  the  alae  through 
small  incisions  in  the  naso-labial  fold  on  each  side  of  the  nose.  It  is 
very  difficult  to  tunnel  along  the  ala  without  perforating  either  the  skin 
or  the  mucous  membrane. 

Free  bone  (from  tibia,  ribs,  and  elsewhere,  Israel,  Depage.  and 
others)  has  been  used  to  fill  out  the  depression  in  saddle  nose  (either 
in  a  single  piece  or  split  and  folded  like  a  roof)  in  much  the  same  manner 
as  just  described  for  cartilage,  but  in  my  experience  bone  is  not  so 
satisfactory.  Rib  bone  with  its  adjacent  cartilage  has  been  used,  the 
bone  to  form  contact  with  the  nasal  bone,  and  the  cartilage  to  extend 
beyond,  but  I  can  see  no  advantage  in  this  over  the  entire  cartilage 
graft.  It  is  probably  the  first  step  on  the  part  of  those  operators 
who  previously  vigorously  defended  the  use  of  bone  as  against  cartilage, 
to  change  to  cartilage,  as  they  surely  will  w^hen  they  become  more 
familiar  with  its  use. 

In  the  severe  cases  in  which  the  nasal  cavity  has  to  be  opened  in 
order  to  depress  the  tip  of  the  nose,  the  opening  should  be  closed  with 
a  flap  having  its  skin  surface  inside,  the  tip  held  in  the  desired  position 
by  means  of  some  rigid  material,  and  the  surface  defect  closed.  To 
effect  this  several  operations  have  been  devised.  I  shall  consider 
only  those  whose  principles  are  correct;  they  may  be  modified  or  com- 
bined to  suit  the  individual  case. 

Cheyne  and  Burghard's  Operation  for  the  Correction  cf  Marked 
Saddle  Nose. — A  vertical  incision  is  made  in  the  midline  from  the  root 
of  the  nose  downward  as  far  as  necessary.  Transverse  incisions  are 
carried  across  both  ends  of  the  vertical  incision  and  flaps  are  laid  back. 
The  cartilage  is  then  separated  from  the  bone  by  a  transverse  incision 
which  opens  into  the  nasal  cavity,  and  the  tip  of  the  nose  is  pulled 
down  into  normal  position.  An  incision  starting  about  1.2^  cm. 
{}-'2  inch)  above  the  root  of  the  nose,  and  0.312  cm.  (}g  inch)  from  the 
midline  is  carried  vertically  upward  to  the  hairline.  Then  another 
parallel  incision  is  made  0.312  cm.  {}i  inch)  on  the  other  side  of  the 
midline.  A  transverse  cut  connects  these  incisions  above.  The  tissues 
are  divided  down  to  the  bone.  This  marks  out  a  flap  0.625  cm.  (}i^ 
inch)  wide  with  its  base  near  the  root  of  the  nose.  Then  with  a  chisel 
the  superficial  portion  of  the  outer  table  of  the  bone  is  raised  with  the 
flap,  the  bone  is  broken  across  at  the  base  and  the  flap  is  turned  down. 
The  flap  consists  of  a  narrow  strip  of  skin  with  a  thin  layer  of  the  frontal 
bone,  and  should  be  long  enough  to  reach  the  cartilaginous  edge  of  the 


464 


PLASTIC    SURGERY 


gap  in  the  nose  when  the  tip  is  in  its  normal  position.  The  epithehal 
surface  of  the  flap  above  the  opening  into  the  nose  is  denuded,  and  the 
end  is  then  stitched  to  the  cartilaginous  portion,  so  that  its  skin  surface 
covers  the  opening  into  the  nose.  The  lateral  skin  flaps  are  loosened 
and  closed  over  the  raw  surface  of  the  bone  flap  in  the  midline  and  the 
wound  on  the  forehead  is  sutured.  Three  weeks  later  the  pedicle  of 
the  reflected  flap  is  severed,  and  the  parts  adjusted. 

The  authors  admit  that  there  is  usually  sinking  of  the  bridge  when 
the  operation  is  performed  as  above  described,  so  that  secondary- 
implantation  of  bone  or  cartilage  becomes  necessary  (Icig.  501). 


I  3  4 

Fig.  501. — Operation  for  saddle  nose  (Cheyne  and  Burghard). — i.  Lines  of  incisions, 
A,  the  skin,  periosteum  and  bone  flap  from  the  forehead.  This  flap  extends  to  the  hair 
line.  BB' the  lateral  flaps.  2.  The  forehead  flap  A  and  the  lateral  flaps  BB' reflected.  The 
tip  of  the  nose  pushed  down.  Note  opening  into  the  nose  cavity  just  aboVe  tip.  3.  The 
frontal  flap  turned  down  and  sutured.  4.  The  lateral  flaps  are  shifted  in  and  sutured  over 
the  frontal  flap. 

]My  criticism  of  the  method  is  that  the  frontal  flap  is  too  narrow 
throughout  and  that  consequently  its  blood  supply  is  doubtful.  With 
a  broader,  more  flaring  pedicle,  and  a  wider,  thicker  flap,  the  results 
would  be  better. 

Nelaton  and  Ombredanne's  Operation. — Through  a  small  incision  at 
the  hairline  a  tunnel  is  burrowed  between  the  periosteum  and  the  bone, 
and  a  piece  of  costal  cartilage  about  5.  cm.  (2  inches)  long  is  inserted 
vertically  and  exactly  in  the  midline.  Six  weeks  later  an  inverted 
U-shaped  incision  is  made,  the  middle  of  which  extends  as  far  above  the 
eyebrows  as  it  is  desired,  to  depress  the  tip  of  the  nose.     The  arms  of 


SURGERY  OF  THE  EXTERNAL  NOSE 


465 


the  U  spread  somewhat  at  the  inner  ends  of  the  eyebrows,  extend 
downward  as  far  apart  as  the  eyes  will  permit,  and  then  along  the  fold 
between  the  nose  and  the  cheeks,  to  points  just  above  the  alae.  The 
flap  is  dissected  free  and  folded  down,  and  at  a  point  about  1.5  cm. 
(^^  inch)  above  the  tip  of  the  nose  a  transverse  incision  is  made  into 
the  nose,  so  that  the  tip  may  be  brought  down  into  normal  position. 
This  will  bring  down  the  free  end  of  the  flap  to  the  level  of  the  eyebrows. 
The  second  flap  containing  the  cartilage  is  then  raised,  as  shown  in  the 
diagram,  care  being  taken  to  preserve  its  blood  supply.  The  entire 
periosteum  under  the  flap  may  be  raised  with  it,  but  my  preference 


V^^        /^^^"^ 


^:  \\\\  \;'j 


I  234 

Fig.  502. — Operation  for  marked  saddle  nose  (modified  from  Nelaton  and  Omhredanne). 
I.  Shows  incisions  to  be  made  in  formation  of  flaps.  Note  cartilage  graft  already  implanted 
in  center  of  forehead  flap.  2.  The  nose  flap  dissected  up,  and  the  tip  of  the  nose  lowered 
by  transverse  incision.  3.  The  forehead  flap  turned  down,  and  sutured.  4.  The  nasal 
flaps  replaced,  so  as  to  cover  the  raw  surface  of  the  frontal  flap. 

is  to  save  as  much  as  possible,  and  to  remove  only  that  in  the  immediate 
neighborhood  of  the  cartilage.  The  freed  flap  should  then  be  turned 
down  so  that  its  upper  edge  just  meets  the  lower  edge  of  the  gap  in  the 
lowered  tip  of  the  nose.  The  cutaneous  surface  is  in  this  way  inward 
and  the  tip  is  held  in  position  by  the  cartilage.  The  epithelium  should 
be  removed  from  all  points  where  it  does  not  line  the  opened  nasal 
cavity,  and  the  edges  are  then  sutured  into  the  defect.  The  first  flap 
is  drawn  up  over  that  reflected  from  the  forehead  and  is  sutured.  The 
gap  in  the  forehead  is  either  grafted  immediately,  or  after  the  pedicle 
has  been  cut.  Fifteen  days  later  the  pedicle  of  the  frontal  flap  is  cut, 
and  the  edges  are  fitted  in  (Fig.  502). 

This  is  an  excellent  operation.  The  use  of  cartilage  is  preferable 
to  bone  in  these   cases   for  purposes  of  support.     A  combination  of 

30 


466 


PLASTIC    SURGERY 


this  method  of  using  cartilage  with  the  lateral  flaps  in  Cheyne  and 
Burghard's  operation  might  be  of  use  in  certain  instances  in  which 
the  skin  is  lax. 

Care  must  be  taken  in  operations  of  this  type  to  remove  all  epi- 
thelium from  the  under  surface  of  the  flap  which  is  not  used  for  lining 
the  nasal  cavity. 

J.  B.  Roberts'  Operation  for  Saddle  Nose.— A  deep  incision  is 
made  across  the  transverse  groove  in  the  sunken  region.     This  opens 


Fig.  503. — Operation  for  saddle  nose  (Roberts). — i.  Outline  of  incisions  for  raising 
cheek  flaps.  2.  The  flaps  turned,  skin  surface  inward,  to  line  the  nasal  defect.  The  pedi- 
cles are  severed  subsequently. 

into  the  nasal  cavity  and  allows  the  tip  of  the  nose  to  be  pulled  down. 
A  flap  whose  width  corresponds  to  the  breadth  of  the  gap  is  raised  from 
each  cheek  near  the  naso-labial  fold.  They  are  folded  over  into  the 
gap,  epithelial  surface  inward,  and  the  ends  are  sutured  in  the  midline. 
A  few  sutures  should  also  be  applied  along  the  edges.  The  areas  from 
which  the  flaps  were  raised  may  be  sutured  at  once.  The  raw  surface 
of  the  folded  over  flaps  may  be  allowed  to  cicatrize,  or  better  still  may 


(.^ 


Fig.  504. — Operation  for  saddle  nose,  continued. — i.  The  outline  of  flaps  to  cover  the 
freshened  surface  of  the  lateral  flaps,  either  after  healing,  or  when  they  are  granulating. 
2.   The  flaps  shifted  downward  into  position. 

be  immediately  grafted.     After  healing  is  complete,  the  pedicles  are 
cut  and  fitted  into  position. 

In  order  to  thicken  the  flaps,  and  at  the  same  time  to  improve  the 
appearance  of  the  nose,  the  following  procedure  is  then  carried  out. 
An  inverted  V-shaped  incision  is  made,  having  its  apex  in  the  middle 
of  the  forehead,  and  its  legs  running  downward  to  points  just  below  the 
inner  canthi.     Justabove  the  granulating  or  healed  surface  a  similar 


SURGERY  OF  THE  EXTERNAL  NOSE 


467 


incision  is  made,  and  the  apices  of  these  V-shaped  cuts  are  joined  by 
a  vertical  incision.  This  marks  out  two  rhomboidal  flaps,  with  their 
pedicles  on  the  cheeks  close  to  the  nose.  The  flaps  are  dissected  up 
on  each  side  and  shifted  down  over  the  prepared  area,  so  that  one  lies 
directly  above  the  other.  The  tip  of  each  is  sutured  to  the  pedicle  of 
the  other  (Fig.  503-504). 

This  is  a  good  operation  in  selected  cases,  but  does  not  have  the 
advantage  of  a  rigid  support. 


B 


Fig.  505.- — Method  of  lining  the  finger  flap  when  the  finger  is  used  in  rhinoplastic 
operations  (Baldwin). — i.  The  left  ring  finger  is  split  in  the  midline  on  the  palmar  surface, 
and  transverse  incisions  are  made  at  the  level  of  the  nail  and  of  the  web.  The  tissues  are 
turned  back  and  the  flexor  tendons  are  removed.  2.  A  pedunculated  flap  is  raised  from 
the  lower  abdominal  wall  on  the  right  side;  the  skin  on  the  areas  B  and  C  being  undercut 
and  closed  beneath  it.  Then  the  flap  is  applied  to  the  raw  surface  of  the  finger  and  in  due 
time  the  pedicle  is  cut.  Contracture  is  prevented  by  attaching  the  ends  of  the  marginal 
sutures  to  a  metal  plate  of  the  desired  size. 

In  cases  due  to  severe  trauma,  the  depressed  nasal  bone  may  be 
freed  and  raised  to  reform  the  bridge.  This  should  be  done  through 
a  skin  incision.  A  septal  flap  with  pedicle  above  or  below  may  also 
be  used  to  till  out  the  defect  in  saddle  nose. 

The  Use  of  the  Finger  in  Rhinoplasty.^ — The  linger  has  been  success- 
fully used  in  reconstructing  a  new  nose,  or  for  supporting  a  collapsed 
nose  on  several  occasions  (Hardie,  1875,  Vredena,  Finney,  Watts, 
Baldwin,  McWilliams,  Ludington.  and  others),  and  also  for  the  forma- 
tion of  the  framework  in  severe  cases  of  saddle  nose. 

I  have  noted  that  a  surgeon  seldom  reports  more  than  one  case 
operated  on  by  this  method.  This  may  be  due  to  the  fact  that  only 
one  patient  requiring  this  kind  of  operation  has  come  under  his  care, 


468 


PLASTIC    SURGERY 


but  my  feeling  is  that  it  is  unnecessary  to  lose  a  finger,  when  better 
results  can  be  obtained  by  other  methods. 

In  the  finger  operations,  as  well  as  in  all  others  in  which  reconstruc- 
tion of  the  nose  is  desired,  a  lining  must  be  provided  for  the  nose,  and 
this  may  be  simply  and  effectually  accomplished  by  Baldwin's  method, 
which  is  well  explained  in  the  diagrams  (Fig.  505).  The  fourth  toe 
has  been  used  by  double  transfer,  to  hand,  to  nose  (Kausch),  but  this 
method  seems  unnecessarily  irksome. 

RESTORATION  OF  THE  LOWER  PART  OF  THE 

NOSE 

In  reconstructing  the  lower  portion  of  the  nose  the  Italian  method 
is  found  to  give  the  best  results  with  minimum  scarring.  If  the  nos- 
trils are  destroyed  only  at  the  anterior  portion,  a  single  flap  may  be 


Fig.  506. — Operation  for  restoration  of  the  lower  portion  of  the  nose  (Bayer-Payr) . — -i. 
Outline  of  cheek  flaps.  2.  Flaps  turned  over  and  sutured  in  position.  Note  method  of 
formation  of  columna.  3.  Pedicles  cut  and  sutured  to  stumps  of  alae.  The  surface  may 
be  either  grafted  or  covered  with  an  arm  flap. 

sufiicient,  but  when  the  nostrils  are  completely  or  almost  completely 
destroyed,  an  external  and  an  internal  flap  must  be  provided,  in  order 
to  prevent  contracture.  When  the  destruction  is  not  very  extensive, 
the  internal  flap  may  be  formed  from  the  skin  of  the  nose  itself,  but 
when  the  destruction  is  great,  both  layers  must  be  formed  from  tissue 
obtained  elsewhere. 

Numerous  operations  have  been  devised  for  reconstruction  of  the 
lower  part  of  the  nose,  but  only  two  will  be  considered. 

The  Bayer-Payr  Operation. — A  curved  flap  with  its  base  just  be- 
yond the  ala,  and  extending  downward  outside  the  angles  of  the  mouth, 
is  raised  on  each  side.  The  width  of  the  flap  should  correspond  to  the 
height  to  be  added  to  the  tip  of  the  nose;  the  length  should  be  sufiicient 
to  allow  the  formation  of  the  alae  and  columna.     The  flaps  are  folded 


SURGERY  OF  THE  EXTERNAL  NOSE 


469 


Fig.   S07. 


Fig.  508. 

Operations  for  the  reconstruction  of  the  lower  part  of  the  nose  (modified  from  Nelaton 
and  Omhredanne). 

Fig.  507. — The  use  of  a  flap  from  the  forearm  with  its  pedicle  at  the  wrist. 

Fig.  508. — I.  Outline  of  a  flap  from  the  arm  with  its  pedicle  toward  the  elbow.  The 
dotted  line  indicates  the  final  shape  of  the  flap.  2.  The  arm  in  position  and  the  flap 
sutured  to  the  nose. 


470 


PLASTIC    SURGERY 


over,  the  ends  are  turned  in  (raw  surface  to  raw  surface)  and  sutured  to 
form  a  columna.  The  edges  are  then  sutured  to  the  freshened  edges 
of  the  nose  defect  and  the  cheek  wounds  are  closed.  After  three 
weeks  the  pedicles  are  cut,  turned  in  and  attached  to  the  stumps  of  the 
alae.  The  raw  surface  of  these  flaps  may  be  grafted  or  covered  with 
a  flap  from  the  arm  (Fig.  506). 

This  is  an  excellent  operation,  and  when  used  in  conection  with  the 
arm  flap  is  the  method  of  choice  in  severe  cases. 

Nelatonand  Ombredanne's  Operation  Where  There  is  Destruction 
of  the  Anterior  Segment  of  the  Nostrils.— The  edges  of  the  defect  are 
freshened,  all  adhesions  are  divided,  and  a  flap  from  the  anterior  portion 
of  the  forearm,  with  its  base  toward  the  wrist  is  raised  and  sutured  into 


/-r-^) 


Pig.  509. — Operation  for  the  reconstruction  of  the  lower  part  of  the  nose,  continued 
(modified  from  Nelaton  and  Ombredanne). — i.  The  pedicle  has  been  cut  after  the  flap  shown 
in  Pigs.  507,  508,  2  has  been  transplanted.  The  free  end  of  the  flap  is  trimmed  in  some  such 
manner  as  is  shown  by  the  dotted  lines  in  Pig.  508,  i.  The  columna  may  be  formed  by  in- 
folding the  pedicle  end  of  the  flap,  or  by  cheek  flaps  as  indicated  by  the  dark  lines,  which 
may  be  turned  up  before  the  arm  flap  is  transplanted.  2.  The  columna  and  alee  have  been 
formed  from  cheek  flaps  by  the  Bayer-Payr  method,  and  then  the  raw  surface  covered  by  a 
flap  from  a  distant  part. 


the  defect.  Ten  to  fourteen  days  later  the  pedicle  is  cut.  Several 
weeks  later  the  columna  is  formed  and  inserted  into  the  upper  lip,  and 
the  edges  are  trimmed  and  shaped  (Fig.  507-509). 

Where  the  nostrils  are  completely  destroyed  two  methods  may  be 
employed,  both  of  which  depend  on  the  formation  of  an  internal  and 
an  external  skin  surface  in  the  construction  of  the  nostril.  The  Bayer 
operation  is  performed,  and  then  a  pedunculated  flap  from  the  arm  is 
used  to  cover  it.  The  other  method  is  to  shape  the  flap  from  the  arm  in 
such  a  manner  that  the  edges  may  be  turned  under  to  line  the  nostrils 
with  skin  and  form  the  columna,  after  the  pedicle  has  been  severed. 


SURGERY  OF  THE  EXTERNAL  NOSE 


471 


RESTORATION  OF  THE  AL.E 

Practically  all  of  the  methods  used  in  plastic  surgery  have  been 
employed  in  the  various  operations  described  for  the  restoration  of  the 


Fig.  510. — Operation  for  the  restoration  of  the  ala  (modified  from  Nelalon  and  Om- 
bredanne). —  i.  The  flap  ABC,  from  the  forearm,  is  inserted  in  a  curved  incision  just  below 
the  nostril,  skin  surface  outward,  and  the  pedicle  is  severed  two  weeks  later.  2.  The 
edges  of  the  nose  defect  are  freshened.  The  flap  is  twisted  and  rolled  so  that  skin  surface 
is  inward,  and  is  sutured  to  the  inner  margin  of  the  defect. 

alae.  The  type  of  operation  to  be  selected  depends  largely  on  the 
amount  of  destruction,  and  the  operation  best  suited  to  each  case  should 
be  carefully  considered.  If  the  entire  ala  is  destroyed,  the  problem  is 
much  more  complicated  than  when  a  stump 
is  left  on  which  to  fasten  the  newly  formed 
ala. 

Flaps  from  the  forehead  have  been  used 
by  DietTenbach,  Labat,  Szymanowski,  and 
others,  but  the  same  objection  (that  of  im- 
planting a  single  unlined  flap)  obtains  here  as 
in  the  more  extensive  operations.  There  is 
also  the  great  disadvantage  of  extensive  scar- 
ring, which  may  be  more  disfiguring  than  the 
defect  to  be  repaired.     This  method  is  not  to  '^««.<f.— The  free  end  of  the 

'■  _  _  nap  IS  turned, back  on  itself, 

be  advised  except  in  the  treatment  of  some-  covering  the  raw  surface,  and 

1      .  .  •  ]    I-      i  1    ii.  1  Ci.         forms  the  nostril  with  skin  in- 

what    extensive    detects,  and  then  only  after  g-^g  ^^^  outside, 
preliminary  lining  of  the  end  of  the  flap. 

The  Italian  method  may  also  be  used  with  advantage  as  follows: 
Raise  a  flap  from  the  forearm  and  fold  the  free  end  on  itself,  after  includ- 
ing a  thin,  shaped  plate  of  rib  cartilage.  Then,  after  healing  is  complete, 
freshen  the  edges  of  the  defect,  split  the  folded  margin  of  the  flap,  raise 
the  arm,  and  suture  it  to  the  nose.  After  ten  days  or  two  weeks  cut  the 
pedicle,  and  later  trim  the  edges  and  shape  the  ala. 


Fig.    511. — Operation   for 
the  restoration  of  the  ala.  con- 


472  PLASTIC    SURGERY 

Nelaton  and  Ombredanne  have  used  an  arm  flap  in  the  following 
manner:  A  long,  fairly  narrow  flap  of  skin  and  subcutaneous  fat  is 
raised  from  the  middle  third  of  the  forearm,  and  the  extremity  is  sutured 
(the  skin  surface  exposed)  into  an  oblique  incision  extending  downward 
and  inward  from  the  naso-labial  fold,  outside  the  destroyed  ala,  to  a 
point  bsl  Dw  the  septum.  Two  weeks  later  the  pedicle  is  cut,  the  nostril 
defect  and  the  external  border  of  the  flap  are  freshened,  and  the  flap  is 
twisted  and  folded  so  that  its  skin  surface  is  inward.  In  this  position  it 
is  sutured  to  the  mucous  edge  of  the  defect.  The  flap  is  then  folded 
back  on  itself,  raw  surface  to  raw  surface,  and  sutured  so  that  there  is 
skin  on  both  sides,  and  what  was  originally  the  inner  edge  of  the  flap  is 
now  the  inferior  border.  There  is  a  considerable  amount  of  excess 
tissue  which  can  be  trimmed  subsequently  (Fig.  510-511). 

This  method  does  not  seem  as  useful  as  that  which  I  have  described 
just  above,  and  is  much  more  complicated. 

The  French  Method 

The  majority  of  operations  devised  for  restoration  of  the  ala  have 
called  for  the  use  of  sliding  flaps.  If  the  defect  is  of  any  size,  single 
unlined  flaps  are  contraindicated.  The  use  of  a  flap  including  the  full 
thickness  of  the  lip  (Blandin)  is  not  advisable. 

In  some  small  defects,  flaps  may  be  turned  down  from  the  nose  itself 
to  line  the  cavity.  Michon  has  devised  an  operation  for  Hning  the 
skin  flap  with  mucous  membrane  flaps  from  the  septum;  and  Thompson 
has  used  a  muco-cartilaginous  flap  from  the  septum  for  the  same 
purpose,  but  both  methods  are  unsatisfactory.  Flaps  through  the  full 
thickness  of  the  nose,  including  the  rim  of  the  defect  have  been  shifted 
down  to  form  the  margin  of  the  ala,  and  the  defect  above  has  been  filled 
with  flaps  from  elsewhere. 

Denonvilliers'  Operation  for  Restoration  of  the  Ala.^Denon- 
villiers  restored  the  ala  by  sliding  downward  over  the  defect  a  pedun- 
culated flap  of  skin  from  the  side  of  the  nose  (Fig.  512).  The  pedicle 
may  lie  anteriorly  near  the  tip  of  the  nose,  or  toward  the  cheek  (Tillaux) . 
The  defect  left  by  shifting  the  skin  down  may  be  grafted  or  aflowed  to 
granulate  (Fig.  513). 

Mutter's  Operation. — The  edges  of  the  defect  are  freshened  by  an 
inverted  V  incision,  and  from  the  end  of  the  outer  arm  of  the  V  a  hori- 
zontal incision  is  made  outward  on  the  cheek.  The  skin  is  undermined, 
the  entire  flap  is  shifted  toward  the  midline  across  the  defect  and 


SURGERY  OF  THE  EXTERNAL  NOSE 


473 


sutured.  In  this  operation  there  is  no  attempt  at  forming  a  norm  il 
looking  ala,  but  the  appearance  may  be  improved  by  subsequent 
operations  (Fig.  514). 


Fig.  512.  Fig.  513. 

Fig.  512. — Denonvilliers'  operation  for  the  reconstruction  of  the  ala  (Duvernoy). — 
I  and  2.  The  flaps  of  skin  ABC,  with  pedicle  on  the  nose  near  the  midline,  or  on  the  cheek, 
are  raised,  and  shifted  downward  to  cover  the  ala  defect. 

Fig.  513. — -Tillaux's  operation  for  the  reconstruction  of  the  ala  (Duvernoy). — i  and  2. 
This  operation  differs  from  that  of  Denonvilliers'  only  in  that  the  pedicle  of  the  flap  ABC 
is  on  the  cheek. 

Sedillot's  Operation.^A  quadrilateral  flap  is  marked  out  with  its 
base  at  the  point  where  the  cheek  should  meet  the  absent  ala,  outside 
of  and  below  it.  The  upper  incision  should  enter  the  nostril;  the  end 
of  the  lower  incision  should  be  far  enough  away  not  to  interfere  with  the 


Fig.  514. — Operation  for  the  restoration  of  the  ala  (Miitler). — i.  The  margin  of  the 
defect  is  excised  (or  turned  down)  by  the  incision  BAC.  The  horizontal  incision  CD  is 
then  made,  and  the  cheek  flap  is  undermined.  2.  The  cheek  flap  is  shifted  toward  the 
midline,  the  point  B  and  C  being  approximated. 

blood  supply.  It  should  be  long  enough,  when  raised,  to  be  sutured 
without  tension,  and  wide  enough  to  fill  the  gap.  The  pedicle  is  twisted 
so  that  the  curl  of  the  ala  is  reproduced  and  the  skin  surface  is  outside 
(Fig.  515). 

Several  other  operations  of  this  type  have  been  done  with  different 
shaped  flaps. 


474 


PLASTIC    SURGERY 


A.  Nelaton's  Operation. — A  quadrilateral  flap,  with  its  pedicle  above, 
is  raised  from  the  fold  between  the  nose  and  the  cheek.  When  the  outer 
part  of  the  ala  is  intact  it  will  be  necessary  to  excise  a  small  triangular 
area  of  skin  above  the  defect.  The  flap  is  then  shifted  in  across  the  skin 
that  remains  on  the  side  of  the  nose,  and  sutured  over  the  defect.     The 


Fig.  515. — Sedillot's  operation  for  the  restoration  of  the  ala  (Duvernoy) . — i.  The  flap 
CABD,  with  its  pedicle  near  the  nose,  is  outlined  and  raised.  2.  It  is  twisted  so  that  the 
skin  surface  is  outward,  and  the  pedicle  forms  the  curl  of  the  ala. 

small  triangular  area  may,  at  times,  be  turned  down  with  its  pedicle 
at  the  margin,  to  act  as  a  partial  lining  for  the  cheek  flap.  The  cheek 
defect  is  sutured,  if  possible;  otherwise  it  is  grafted  (Fig.  516). 

Preidlsberger's  Operation.— A  rectangular  flap  2.  X3.  cm.  fiXiH 
inches)  with  its  base  close  to  the  defect,  is  raised  from  the  cheek  and 


:^^^"~~^ 


Fig.  516. — A.  Nelaton's  operation  for  the  restoration  of  the  ala  (Duvernoy). —  i.  The 
flap  D,  with  its  pedicle  upward,  is  raised.  The  triangle  of  skin  C  is  either  excised,  or 
turned  down  to  line  the  flap  D,  which  is  jumped  over  the  area  E.  2.  Shows  the  flap  in 
position.      The  shaded  area  may  be  grafted. 

turned  backward  with  the  skin  surface  inward.  It  is  sutured  to  the 
freshened  edges  of  the  defect.  The  area  from  which  it  has  been  raised 
is  sutured,  and  the  raw  surface  of  the  flap  is  grafted  with  Olher-Thiersch 
grafts  (Fig.  517). 

For  all  of  these  operations  just  described  for  the  restoration  of  the 


SURGERY  OF  THE  EXTERNAL  NOSE 


475 


ala  the  operators  have  used  sliding  flaps  of  single  thickness  skin.  This 
means  that  in  all  cases,  except  those  which  are  small,  there  will  be 
contracture  and  subsequent  deformity.  None  of  these  operations  are 
to  be  recommended  if  done  as  they  were  originally  described,  but 
there  arc  possibilities  in  each  one  of  these  procedures  if  the  flap  can  be 


Fig.  517. — Operation  for  the  restoration  of  the  ala  (Preidlsberger). — i.  Outline  of  in- 
cision to  raise  the  flap  ABCD,  with  base  adjacent  to  the  defect.  2.  The  flap  raised,  turned 
over,  and  sutured  into  the  freshened  margins.      The  raw  surfaces  may  be  grafted. 

lined  with  epithelium  before  being  shifted.  This  can  easily  be  done  by 
the  buried  method  and  in  addition  a  bit  of  cartilage  may  be  inserted 
in  cases  requiring  stiffening  before  the  flap  is  shifted.  In  many  in- 
stances marginal  flaps  may  be  turned  down  to  serve  as  a  lining. 


Fig.  518. — -Operation  for  the  restoration  of  the  ala  {Bouisson). —  i.  The  flap  A  with 
pedicle  adjacent  to  the  nasal  defect  is  raised,  turned  over  (skin  surface  inward),  and  sutured 
to  the  margin  of  the  defect.  2.  The  flap  B,  with  its  pedicle  on  the  cheek,  is  raised  and 
shifted  toward  the  midline,  and  sutured,  thus  covering  the  raw  surface. 

Ala  defects  have  been  restored  by  the  use  of  double  flaps  (Bouisson), 
one  with  its  skin  surface  turned  in.  the  pedicle  being  close  to  the  margin 
of  the  defect  (somewhat  after  the  method  of  Preidlsberger),  and  the 
other  flap,  with  its  base  away  from  the  defect,  being  shifted  in  to  cover 
it.  I  mention  this  method  merely  for  the  idea  suggested  by  it.  As  a 
matter  of  fact  the  procedure  has  little  to  recommend  it.  and  to  a  large 
extent  has  been  abandoned. 

Bouisson  has  also  proposed  a  similar  method  in  which  he  lowers 


476 


PLASTIC    SURGERY 


a  flap  of  the  cartilaginous  edge  of  the  defect  to  form  the  edge  of  the 
ala  and  then  shifts  in  a  covering  flap  from  the  cheek  (Fig.  518-519). 

Von  Hacker's  Operation  for  the  Restoration  of  the  Ala.— A  flap 
with  its  base  toward  the  cheek,  cut  from  the  entire  thickness  of  the 
nose,  is  shifted  down  and  sutured  to  fill  the  ala  defect.     The  opening 


Fig.  519. — Operation  for  the  restoration  of  the  ala,  utilizing  a  rim  of  nasal  cartilage 
(Bouisson). — i.  The  flap  A,  consists  of  the  skin  and  cartilage  edge  of  the  defect.  It  is 
shifted  down,  turned  raw  surface  outward,  and  is  sutured  in  place.  2.  The  flap  B  from  the 
cheek  is  shifted  in  to  cover  this. 


left  above  by  the  lowering  of  this  flap  is  filled  with  a  pedunculated  flap 
from  the  cheek,  having  its  base  toward  the  nose.  This  is  turned  over 
into  the  defect  and  sutured,  skin  inward.  The  surface  of  the  flap 
may  be  grafted  at  once  or  later,  or  it  may  be  lined  before  the  flap  is 
transplanted.     The  pedicle  is  severed  and  fitted  into  position  after  ten 


12  3 

Pig.  520. — Operation  for  the  restoration  of  the  ala  (v.  Hacker). — i.  The  flap  ac  is 
cut  through  the  entire  thickness  of  the  nose,  and  is  shifted  downward  to  form  the  new  ala. 
2.  The  flap  X  with  its  pedicle  adjacent  to  the  nose  is  then  raised.  The  triangles  dee, 
and  hgc,  are  excised,  and  the  flap  X  is  turned  over  and  sutured  in  to  the  defect,  skin  sur- 
face inward.  3.  The  flap  in  position.  The  raw  surface  is  grafted.  The  pedicle  is  cut 
after  10  to  14  days. 

days  or  two  weeks.     The  wound  from  which  the  flap  is  raised  is  either 
sutured  or  grafted  (Fig.  520). 

Kredel  used  a  triangle  of  cartilage  from  the  ear,  and  F.  Konig 
transplanted  a  section  of  the  full  thickness  of  the  margin  of  the  ear  into 
defects  in  the  ala.     Joseph  used  a  transplant  of  the  full  thickness  of 


SURGERY  OF  THE  EXTERNAL  NOSE 


477 


one  ala,  to  fill  that  in  the  other.  I  have  not  used  these  methods,  and 
see  no  reason  to  mutilate  the  ear  or  other  ala,  when  cartilage  is  so 
easily  obtainable  elsewhere  (Fig.  521-522). 

The  anterior  portion  of  the  inferior  turbinate  has  been  advanced 
to  form  the  lining  and  support  of  a  newly  constructed  ala.  It  is  divided 
as  far  back  as  is  necessary,  is  loosened,  swung  forward  with  the  pedicle 
in  front,  and  attached  to  the  septum.  After  healing  has  taken  place 
the  mucous  membrane  is  removed  from  the  outer  surface  and  a  skin 
flap  is  turned  in  from  the  cheek  to  cover  it.  Later  the  necessary 
shaping  operations  may  be  done.     This  gives  a  rigid  ala  (Hett). 


Fig.  521.  Fig.  522. 

Pig.  521. — Operation  for  the  restoration  of  the  ala  (F.  Kotiig). — The  edges  of  the  defect 
are  freshened,  and  a  section  of  the  same  size  from  the  full  thickness  of  the  ear  is  removed 
and  transplanted.      The  ear  defect  is  closed  by  a  plastic  operation. 

Fig.  522. — Operation  for  closing  a  defect  in  one  ala,  by  means  of  a  free  flap  from  the 
other  {J.  Joseph). — i.  The  outline  of  the  incision  through  the  full  thickness  of  the  nose. 
2.    The  graft  sutured  into  the  defect  in  the  other  ala. 


Restoration  of  the  Tip  of  the  Nose 

At  times  we  are  called  upon  to  reconstruct  the  tip  of  the  nose.  If 
the  destruction  is  of  the  soft  parts  only  the  cartilage  being  intact,  we 
may  graft  the  defect  or  apply  a  thin  flap  from  the  arm.  If  the  soft 
parts  together  with  the  anterior  extremity  of  the  cartilage,  have  been 
destroyed,  the  Indian  and  French  methods  should  not  be  tried,  on 
account  of  the  liability  of  causing  a  deformity  more  unsightly  than 
the  original  defect. 

The  Italian  method,  on  the  other  hand,  is  most  satisfactory  for 
these  cases  and  can  be  used  without  scarring  the  face.     If  cartilage  is 


478  PLASTIC    SURGERY 

needed  to  support  the  tip  it  may  be  implanted  in  the  flap  before  bringing 
it  to  the  nose,  or  inserted  subsequently.  The  same  methods  may  be 
employed  as  have  already  been  described  for  the  restoration  of  the  lower 
part  of  the  nose. 

THE  RESTORATION  OF  THE  LOWER  PART  OF  THE  SEPTUM 

(COLUMNA) 

The  absence  of  the  lower  part  of  the  septum  may  be  extremely 
disfiguring.  The  French  method  is  that  usually  employed  for  the 
restoration  of  the  columna,  and  a  number  of  operations  have  been  de- 
vised. The  Indian  method  causes  unnecessary  scarring,  and  should 
not  be  used,  but  the  Italian  method  may  be  used  with  advantage  in 
certain  cases. 


Pig.  523. — Operation  for  the  restoration  of  the  columna  (Labat). — The  flap  is  raised 
from  the  web  between  the  thumb  and  fingers,  and  the  hand  is  held  in  the  position  shown. 
Two  weeks  later  the  pedicle  is  cut. 

Where  there  is  no  deformity  of  the  nostrils  and  the  tip  of  the  nose 
has  not  collapsed,  any  of  the  simple  methods  of  utilizing  tissue  from  the 
lip  will  be  sufficient.  If  the  nasal  orifice  is  distorted,  and  the  edges 
are  infiltrated  with  scar  tissue  and  are  depressed,  one  must  resort  to 
some  method  in  which  a  support  is  employed.  Where  the  nostrils 
are  retracted  and  drawn  in,  one  of  the  plans  used  for  the  restoration 
of  the  lower  part  of  the  nose  is  applicable. 

Labat's  Operation  for  Restoration  of  the  Coliinina. — A  flap  of  suitable 
size  is  raised  from  the  web  of  the  thumb  and  is  attached  to  the  tip  of  the 
nose,  skin  surface  outward.  The  palm  of  the  hand  is  forward,  the 
thumb  on  one  side  of  the  nose  and  the  fingers  on  the  other.  Ten  days 
later  the  pedicle  is  cut  and  the  end  is  attached  to  the  root  of  the  lip. 
This  type  of  operation  may  be  of  great  use,  and  if  the  flap  is  prepared  in 
advance  by  being  turned  on  itself,  or  if  its  raw  surface  be  grafted  and  a 
piece  of  cartilage  also  implanted,  this  method  has  all  the  advantages 
and  none  of  the  disadvantages  of  the  other  methods  ('Fig.  523). 


SURGERY  OF  THE  EXTERNAL  NOSE  479 

Dupuytren's  Operation.^ A  flap  of  sufficient  width  is  raised  from 
the  upper  lip  down  to.  but  not  including,  the  mucous  membrane.  The 
base  of  the  flap  is  at  the  root  of  the  septum  and  the  tip  is  at  the  vermilion 
border.  It  is  then  twisted  so  that  the  skin  surface  is  exposed,  and  the 
free  end  is  sutured  into  the  tip  of  the  nose.  The  lip  wound  is  then  closed. 
This  operation  can  be  much  improved  by  buried  grafting  of  the  under 
surface  of  the  flap,  which  will  allow  less  subsequent  contracture  (Fig. 

524)- 

Serre's  Operation. — This  operation  is  the  same  as  that  of  Dupuy- 
tren  except  that  the  base  of  the  flap  is  at  the  vermilion  border.  The 
flap  is  raised  and  attached  to  the  tip  of  the  nose;  later  the  pedicle  is 

e 


Fig.  524.  Fig.  525. 

Fig.  524. — Dupuytren's  operation  for  the  restoration  of  the  columna  (Duvernoy). — 
A  rectangular  flap  is  raised  from  the  midline  of  the  upper  lip,  its  base  at  the  root  of  the  sep- 
tum. The  flap  includes  the  full  thickness  of  the  lip,  except  the  mucous  membrane.  It 
is  turned  up  and  twisted  to  bring  skin  surface  outward,  and  is  attached  to  the  tip  of  the 
nose.      The  lip  defect  is  sutured. 

Fig.  525. — Serre's  operation  for  the  restoration  of  the  columna  (Duvernoy). — A  flap 
is  raised  from  the  midline  of  the  skin  of  the  lip,  its  base  being  at  the  vermilion  border.  The 
free  end  is  then  attached  to  the  tip  of  the  nose.  Its  pedicle  is  cut  10  days  later,  and  the 
base  is  attached  to  the  upper  lip. 

cut  and  the  base  is  inserted  into  its  proper  place.  This  operation 
can  also  be  improved  by  buried  grafting  of  the  flap  before  it  is  raised 
(Fig.  525). 

These  operations  which  aim  to  form  the  septum  from  the  full 
thickness  of  the  lip  are  not  desirable,  because  the  mucous  membrane  is 
on  the  exposed  surface  of  the  columna  and  damage  is  done  to  the  lip. 

Lexer's  Operation. — A  flap  of  mucous  membrane  and  the  submucous 
tissue  is  raised  from  the  midline  of  the  under  surface  of  the  upper  lip, 
with  its  pedicle  at  the  base  of  the  septum.  A  short  horizontal  incision 
is  made  through  the  lip  at  the  point  where  the  lip  and  septum  meet. 
After  the  flap  has  been  folded  lengthwise  and  sutured,  raw  surface  to 
raw  surface,  it  is  pulled  through  this  incision  and  is  secured  to  the  tip 
of  the  nose.  The  defect  in  the  mucous  membrane  is  closed  at  once 
(Fig.  526). 


48o 


PLASTIC    SURGERY 


This  operation,  although  simpler,  has  the  disadvantage  of  exposing 
mucous  membrane,  and  I  have  never  yet  seen  lip  mucosa  assume 
the  appearance  of  the  skin. 

Szymanowski's  Operation.— A  flap  is  raised  from  the  skin  of  the 
nose.     Its  pedicle  on  one  side  extends  to  the  nostril,  and  on  the  other 


123  4 

Fig.  526. — Operation  for  restoration  of  the  columna  {Lexer). — i.  The  flap  raised  from 
the  midline  of  the  under  surface  of  the  upper  lip  with  pedicle  above.  Note  freshening  of 
tissue  in  narrow  transverse  area  C,  at  the  base  of  the  flap.  2.  The  notch  D,  on  under 
surface  of  the  nose  is  to  receive  the  tip  of  the  flap.  The  transverse  black  line  indicates 
the  position  of  the  incision  through  the  lip,  which  opens  behind  the  base  of  the  flap.  3. 
The  flap  folded  on  itself  and  sutured  lengthwise.  Sutures  are  placed  to  close  the  defect 
in  the  mucosa.  4.  The  flap  brought  forward  through  the  incision  in  the  lip  and  sutured  to 
the  tip  of  the  nose. 

curves  outward  well  above  it  to  insure  its  circulation.  The  flap  is 
then  shifted  downward  and  its  free  end  is  attached  to  the  upper  lip. 
The  defect  on  the  nose  is  either  sutured  or  grafted.  This  operation 
is  not  to  be  recommended,  but  is  mentioned  to  show  the  type  in  which 
a  flap  from  the  skin  of  the  nose  is  used  (Fig.  527). 


Pig.  527.  Fig.  528. 

Fig.  527. — Operation  for  the  restoration  of  the  columna  (Szytnanowski). — The  flap 
abc,  from  the  skin  of  the  nose  is  shifted  downward,  the  line  b,  being  attached  to  the  upper 
lip. 

Fig.  528. — Demons'  operation  for  the  restoration  of  the  columna  (Duvernoy). — Two 
flaps  are  raised  from  the  skin  and  subcutaneous  tissue  below  each  nostril.  The  base  being 
at  the  nostril  and  the  free  ends  at  the  vermilion  border.  The  area  A,  in  the  raidline  is  un- 
disturbed. The  flaps  are  raised,  rotated  inward,  and  sutured  raw  surface  to  raw  surface. 
The  free  end  of  the  double  flap  is  then  sutured  to  the  tip  of  the  nose. 

Demons'  Operation.— Two  rectangular  flaps  of  skin  and  sub- 
cutaneous tissue  are  raised  from  below  each  nostril.  The  pedicles 
are  above  and  the  free  ends  reach  to  the  vermilion  border.  The  flaps 
are  separated  by  the  skin  in  the  middle  portion  of  the  lip.     They 


SURGERY  OF  THE  EXTERNAL  NOSE 


481 


are  turned  up  and  folded  so  that  the  raw  surfaces  are  apposed,  and  the 
edges  are  sutured.  Then  the  end  of  the  double  flap  is  attached  to  the  tip 
of  the  nose  and  the  lip  wounds  are  closed.  After  healing,  it  may  be 
possible  to  insert  a  piece  of  cartilage  between  the  flaps,  and  in  this  way 
more  rigidity  be  obtained  (Fig.  528). 

Author's  Method  for  Restoration  of  the  Columna. — I  have  made 
a  columna  with  two  liaps  of  skin  and  subcutaneous  tissue,  extending 
transversely  across  the  upper  lip,  just  below  the  base  of  the  nose. 
The  pedicles  were  situated  close  to  the  midline  near  the  anterior 
margin  of  the  floor  of  the  nose,  and  the  free  ends  extended  beyond 


wi^^^^ 


/^^^^\ 


Fig.  529. — Operation  for  the  construction  of  the  columna. — i.  The  dotted  lines  indi- 
cate the  outlines  of  the  flaps  consisting  of  skin  and  subcutaneous  tissue.  2.  Flaps 
raised  and  with  the  raw  surfaces  turned  inward  toward  the  midline  are  sutured  together, 
skin  surface  outward.  The  free  end  of  the  approximated  flaps  is  sutured  to  the  tip  of  the 
nose. 


the  alas.  The  flaps  were  raised  and  turned  inward,  raw  surface  to 
raw  surface,  and  then  the  end  of  the  double  flap  was  sutured  to  the 
tip  of  the  nose.  The  flaps  should  be  cut  wide  enough  to  give  the  lip 
the  desired  shortening,  and  should  be  long  enough  to  reach  the  tip 
of  the  nose  without  tension  after  being  sutured  together.  The  lip 
wounds  left  after  raising  the  flaps  are  sutured  (Fig.  529). 

This  type  of  operation  for  the  reconstruction  of  the  columna  is 
suitable  only  for  those  cases  in  which  the  upper  lip  is  very  long.  It 
accomplishes  the  double  purpose  of  shortening  the  lip  and  forming  the 
columna. 

Ch.  Nelaton's  Operation  for  Restoration  of  the  Columna  with  a 
Rigid  Support. — A  small  curved  incision  with  its  convexity  downward  is 
made  just  below  the  septum.     The  soft  parts  above  the  alveolar  process 


482 


PLASTIC    SURGERY 


are  divided,  and  then  with  a  gouge  a  portion  of  the  rudimentary  septum 
is  removed,  long  enough  to  form  the  new  columna.  This  rigid  flap 
(bone  or  cartilage)  is  turned  down  so  that  its  posterior  extremity 
can  be  sutured  to  the  tip  of  the  nose.  This  brings  mucous  membrane 
outward  and  exposes  the  uncovered  bones,  or  cartilage  within.  The 
circulation  of  the  flap  is  preserved  by  the  soft  parts  directly  above  the 
ends  of  the  skin  incision.  Healing  may  be  stimulated  by  wrapping 
a  thin  Ollier-Thiersch  graft  around  the  newly  formed  columna  on 
the  chance  of  having  some  of  it  adhere  to  the  raw  surface  (Fig.  530). 


Pig.  530. — Ch.  Nelaton's  operation  for  the  restoration  of  the  columna  (Duvernoy) . — 
I.  Through  a  curved  incision  the  gouge  is  raising  a  portion  of  the  rudimentary  septum, 
consisting  of  mucous  membrane,  bone  and  cartilage,  with  its  base  at  the  upper  lip.  2, 
The  rigid  flap  is  turned  forward,  and  attached  to  the  tip  of  the  nose. 


Secondary  Rhinoplastic  Operations 

Only  rarely  can  a  rhinoplastic  operation  of  any  extent  be  done 
without  a  number  of  secondary  operations  to  shape  and  mold  the 
transplanted  tissue.  Many  of  these  retouching  operations  are  also 
used  to  correct  malformations  of  the  nose  (simply  to  improve  ap- 
pearance), but  in  the  latter  group  the  operator  is  usually  fortunate 
enough  to  have  normal  tissues  to  deal  with  and  not  scar  infiltrated 
material. 

These  trimming  and  shaping  operations  are  extremely  difficult, 
and  a  bad  situation  is  often  made  worse  by  an  unskillful  operator 
or  a  poorly  planned  operation. 

Oblique  Nose 

After  rhinoplastic  operations  the  nostrils  may  not  be  of  the  same 
height.  For  correction  in  these  cases  several  operations  have  been 
devised. 


SURGERY  OF  THE  EXTERNAL  NOSE 


483 


Dieffenbach's  Operation. — An  incision  made  in  the  midline  the  full 
length  of  the  nose.  A  triangle  of  tissue  of  the  desired  size  with  its  base 
at  the  midline  is  removed  from  the  long  side.     The  incisions  are  closed 


:Fig. 


:). 


Fig.  531. — Dieffenbach's  operation  for  the  correction  of  an  oblique  nose  (Szytnanowski). 
—  I  and  2.  The  incision  db  is  made  through  the  soft  parts  in  the  midline,  from  the  root  to 
the  tip  of  the  nose.  The  triangle  of  tissue  cde  (which  should  vary  in  width  according  to 
circumstances),  is  removed,  and  the  wounds  are  closed. 

J.  Joseph's  Operation. — An  irregular  elliptic-shaped  section  of 
tissue,  including  the  full  thickness,  is  removed  from  the  long  side  of  the 
nose.  This  section  is  obliquely  placed  and  extends  from  the  edge  of  the 
ala  to  beyond  the  midline.  The  width  depends  on  the  extent  to  which 
the  nose  is  to  be  shortened.     The  wound  is  then  closed  (Fig.  532). 


Fig.  s:i2. — Operation  for  the  correction  of  a  lowered  ala  (J.  Joseph). — i.  The  shaded 
portion  represents  the  area  excised,  including  skin,  cartilage  and  mucous  membrane.  2. 
The  defect  closed  and  the  ala  brought  up  into  proper  position. 

In  both  of  these  operations  no  permanent  good  can  be  accomplished 
unless,  in  an  additional  procedure,  the  ala  on  the  affected  side  is  sepa- 
rated from  the  cheek  and  raised. 

To  Reduce  the  Size  of  the  Nose 
If  the  newly  made  nose  is  too  large  it  may  be  reduced  by  removing 
sections  of  the  skin  and  underlving  tissue.     When  the  nose  is  naturally 


484 


PLASTIC    SURGERY 


large,  or  has  been  increased  in  size  by  trauma,  in  addition  to  the  skin 
sections  of  the  nasal  and  septal  cartilages  may  have  to  be  removed, 
before  any  permanent  result  is  obtained  (Mikulicz,  Joseph,  Kolle,  and 
others) . 


Fig.  533. — Dieffenbach's  operation  for  reducing  the  size  of  the  nose  (Szymanowski) . — 
I  and  2.  The  shaded  area  indicates  the  defect  left  after  the  excision  of  a  vertical  and  hori- 
zontal segment  of  skin  and  subcutaneous  tissue.  A  similar  excision  should  be  done  on" the 
other  side  of  the  nose,  and  the  wounds  then  closed. 

The  bridge  of  the  nose  may  also  be  very  prominent,  either  naturally 
or  following  injury.  This  prominence  may  be  reduced  by  trimming 
the  bone  and  cartilage  subcutaneously  through  an  incision  at  the  tip 


123  4 

Fig.  534. — -Joseph's  operation  for  reducing  the  size  of  a  large  nose  (Roberts). — i. 
Shaded  portion  indicates  area  of  tissues  excised.  2  A-D.  Other  shapes  which  may  be 
excised  to  suit  conditions.  3.  A.  Nasal  bone.  B.  Maxillary  bone.  C.  Triangular  cartilage. 
D.  Cartilage  of  the  ala.  The  shaded  portion  indicates  the  tissues  removed.  4.  A.  Eth- 
moid bone.  B.  Quadrangular  cartilage.  C.  Vomer.  Shaded  portion  indicates  the  area 
removed. 

of  the  nose  fMonks);  by  the  submucous  method  of  Roe,  and  others; 
or  by  the  external  method.  There  is  practically  no  visible  scarring 
following  the  first  two  methods,  but  my  own  preference  in  these  cases  is 
for  direct  exposure  through  a  midline,  a  lateral,  or  a  transverse  curved 
incision  over  the  bridge,   depending  on  conditions.     The  soft  parts 


SURGERY  OF  THE  EXTERNAL  NOSE 


48< 


Fig.  535. — Prominent  and  thickened  bridge  of  nose  caused  by  repeated  trauma. — 
I.  Before  operation.  The  case  was  complicated  by  the  occurrence  of  lupus  of  the  skin  on 
the  bridge.  For  this  reason  it  was  necessary  to  excise  all  of  the  involved  skin.  After  this 
was  done  a  sufficient  amount  of  bone  and  cartilage  was  removed  to  reduce  the  prominent 
size  of  the  bridge,  and  the  length  was  also  reduced  slightly.  On  account  of  the  excision  of 
the  skin  the  defect  was  grafted.  2.  Result  four  months  after  operation.  The  scar  on  the 
bridge  is  the  area  grafted.  In  a  case  of  this  type  without  skin  involvement,  operated  on  by 
the  open  method  very  little  scarring  follows. 


Fig.  536. — Operation  for  reducing  the  size  of  the  nose  {Mikulicz). — i.  The  lower  por- 
tion of  the  septum  is  divided  along  the  dotted  line  CD  and  is  removed;  the  tip  of  the  nose 
is  incised  along  the  line  BC.  2.  The  tip  A,  is  attached  to  the  upper  lip.  The  flap  BCD, 
is  folded  in  to  line  and  form  the  border  of  the  nostrils. 


486 


PLASTIC    SURGERY 


are  divided  and  retracted  until  the  bone  and  cartilage  are  exposed, 
and  the  desired  amount  is  removed  from  the  bridge  and  from  the  sides. 
The  soft  parts  are  then  closed  and  firm  pressure  is  made  over  the  site 
of  operation. 


:  ^  3  4  5 

Fig.  537. — Deformity  following  the  injection  of  paraffin  to  correct  a  saddle  nose. — 
I.  Note  the  great  thickening  between  the  ej^es  and  on  the  bridge  of  the  nose  due  to  the 
injected  paraffin.  Also  the  deep  puckered  groove  on  the  side  of  the  nose.  A  considerable 
amount  of  the  infiltrated  tissue  was  removed  in  several  operations.  2  and  3.  A  peduncu- 
lated flap  from  above  (see  median  scar)  with  its  pedicle  below,  was  turned  down  to  fill  the 
groove  on  the  side  of  the  nose.  Several  other  shaping  operations  were  done.  4  and  5. 
The  result  two  years  later.      Note  the  shape  of  the  bridge. 

To  Lengthen  the  Nose 

A  nose  which  is  too  short  may  be  lengthened  by  the  inverted  V- 
shaped  incision,  the  point  of  which  is  in  the  midline  about  on  the  level 

3?    -    SC  ^        S 


Fig.  538.- — Pirogoflf's  operation  for  lengthening  the  nose  (Szymanowski). — i  and  2. 
The  dark  line  indicates  the  V-shaped  incision.  The  tissues  are  loosened,  the  tip  is  pushed 
down,  and  the  wounds  are  closed. 

of  the  canthi.  the  ends  of  the  legs  being  in  the  fold  between  the  cheek 
and  nose  just  above  the  alse  (Fig.  538). 


SURGERY  OF  THE  EXTERNAL  NOSE  487 

The  flap  is  raised,  adhesions  are  loosened,  and  the  wound  is  closed 
in  the  form  of  an  inverted  Y.  The  success  of  this  simple  method  de- 
pends on  the  normal  condition  of  the  tissues,  and  at  best  it  is  not  very 
succ-'ssful  wh-Mi  the  nose  is  too  wide. 

To  Narrow  the  Nose 

Szymanowski's  Operation. — A  broad  triangle  of  tissue  with  its 
apex  in  the  midline  just  above  the  vermilion  border  and  its  base  extend- 
ing from  the  inner  edge  of  the  ala  on  one  side  to  the  inner  edge  on  the 


Fig.  539- 


r 


Fig.  540. 
Szymanowski's  operations  for  narrowing  the  nose. 
Fig.   539. — I.   The  shaded  area  indicates  the  size  and  shape  of  the  broad  triangle  of 
tissue  removed  from  the  tissue  of  the  upper  lip.      2.  Shows  the  edges  sutured. 
Fig.   540. — Two    triangular    areas    may    be    removed    instead    of    one. 

Other,  is  removed  from  the  upper  lip.  The  ala?  are  loosened,  and  the 
wound  is  closed  in  the  midline.  The  tissues  are  held  together  by  a 
traction  stitch  through  the  base  of  the  nose  (Fig.  539). 

The  removal  of  a  triangle  of  tissue  from  beneath  each  nostril,  a 
strip  of  skin  being  left  between,  will  accomplish  the  same  purpose  with 
less  damage  to  the  upper  lip  (Fig.  540-541). 

To  Raise  a  Flattened  Nostril 

Szymanowski's  Operation.— The  ala  is  detached  by  a  transverse 
incision  through  the  full  thickness  of  the  tissues  just  above  the  flat- 


488 


PLASTIC    SURGERY 


tened  nostril.     Next,  a  cut  perpendicular  to  the  first  incision  is  made 
down  through  the  border  of  the  nostril.     The  tissue  inside  the  nose 


Fig.  541. — Operation  for  narrowing  the  base  of  the  nose  (Kolle). — i.  The  dark  and 
also  the  dotted  lines  indicate  the  incisions  made  for  removal  of  tissue.  2.  The  edges 
approximated. 


g> 


<^ 


Fig.  542.  Operation  for  elevating  an  abnormally  flat  nostril  (Szymanowski). — The 
solid  line  indicates  the  T-shaped  incision  through  the  full  thickness  of  the  nostril.  The 
insert  indicates  the  method  of  closure  of  the  edges  after  beveling  the  margins. 


A  B 

Fig.  543. — Operation  for  correcting  an  abnormally  flat  nostril  (J.  Joseph). — A.  The 
shaded  area  represents  the  tissue  excised  through  the  thickness  of  the  lip.  B.  The  edges  are 
closed  as  in  an  operation  for  harelip. 

along  the  margins  of  the  flaps  is  beveled,  and  the  edges  are   closed 
(Fig.  542). 

J.  Joseph's  Operation.— A  section  is  removed  through  the  full 
thickness  and  height  of  the  lip,  extending  from  the  center  of  the  nostril 


SURGERY  OF  THE  EXTERNAL  NOSE 


489 


down  to  and  including  the  margin  of  the  lip.  The  width  of  the  strip 
depends  on  the  amount  of  narrowing  desired.  The  ala  on  that  side 
must  be  thoroughly  freed  before  suturing  (Fig.  543). 

To  Lengthen  the  Ala 

Polaillon's  Operation.^ — Two  curved  llaps  adjacent  to  each  other 
are  raised,  the  one  being  formed  by  the  outer  end  of  the  ala  and  the 


I  2 

Fig.  544. — Operation  for  lengthening  the  ala  (Polaillon).- — i  and  2.  The  flaps  mno, 
and  nop  are  raised,  nop  is  drawn  forward  and  sutured  beneath  the  other  flap,  which  is 
stretched  outward,  and  sutured  into  the  cheek  defect. 

Other  from  the  cheek,  as  shown  in  the  diagram.  The  cheek  flap  is 
drawn  under,  the  ala  flap  is  stretched  outward  to  fill  the  defect  left 
by  shifting  in  the  cheek  flap,  and  both  are  sutured  in  position  (Fig.  544). 


Pig.  545. — Operation  for  lengthening  and  narrowing  the  alae  (Kolle). — i.  The  dark 
lines  indicate  the  incisions  for  the  outer  triangles  of  the  diamond-shaped  pieces  of  tissue 
to  be  removed.  The  bases  of  the  triangles  meet  at  the  anterior  rim  of  the  nostrils.  2. 
The  edges  sutured. 


To  Reduce  the  Thickness  of  the  Ala 

Reduction  in  the  thickness  of  the  ala  is  often  necessary,  especially 
after  double  thickness  flaps  have  been  used  to  construct  the  nostrils. 
This  is  best  accomplished  by  the  excision  of  elliptical  sections  from  the 
margins  (Linhart,  and  others)  (Fig.  546). 


490 


PLASTIC    SURGERY 


Atresia  of  the  Nostrils 

Atresia  of  the  nostril  is  exceedingly  difficult  to  correct.  It  may 
occur  after  rhinoplastic  operations,  or  may  be  caused  by  disease.  If 
atresia  is  accompanied  by  loss  of  substance,  then  it  is  best  to  perform 
one  of  the  operations  previously  described,  and  completely  reconstruct 


Fig.    546. — Operation    to   reduce   the   thickness   of   the  alse   (Linhart). — ElUptical-shaped 
sections  of  tissue  are  removed  from  the  alse,  and  the  wounds  are  closed. 


the  nostril.     The  restoration  may  be  made  by  the  Italian  method,  or 
in  suitable  cases,  by  that  devised  by  Jalaquier. 

Jalaquier's  Operation. — A  narrow  quadrilateral  flap  is  raised  from 
the  naso-labial  tissue  below  the  nostril,  with  its  pedicle  above  and  con- 
tinuous with  the  ala.  The  ala  is  then  completely  detached  and  the 
under  surface  of  the  quadrilateral  flap  is  sutured  to  the  raw  internal 


Fig.  547. — Operation  for  the  relief  of  atresia  of  the  nostril  (Jalaquier). —  i.  The  flap  A 
(which  is  continuous  with  the  ala)  is  raised,  and  after  freeing  the  nostril  it  is  turned  under, 
and  forms  the  lining  of  the  ala.  The  flap  B  is  then  raised  and  is  shifted  down  to  fill  the 
defect  left  by  raising  A.      2.   Shows  the  flaps  in  position,  and  the  wounds  closed. 


surface  of  the  ala.  A  long  quadrilateral  flap  is  then  raised  from  the 
cheek  with  its  pedicle  at  the  base  of  the  ala.  This  is  shifted  and  sutured 
into  the  defect  made  by  raising  the  first  flap,  care  being  taken  to  shape 
the  posterior  border  to  form  the  ala  when  suturing  the  cheek  defect 
(Fig.  547). 

Absence  of  the  Nose  (Congenital) 

For  the  correction  of  this  very  rare  condition,  Maisonneuve's  pro- 
cedure may  be  effective. 


SURGERY  OF  THE  EXTERNAL  NOSE 


491 


Maisonneuve's  Operation.— A  V-shaped  incision  is  made  through 
the  full  thickness  of  the  lip.  with  its  apex  exactly  in  the  midline  at  the 
vermilion  border.  The  arms  of  the  V  end  at  the  points  where  the  nos- 
trils should  be,  and  from  these  points  horizontal  incisions  are  made 
outward  as  far  as  may  be  necessary.     The  skin  above  the  horizontal 


Fig.  548. — Operation  for  the  construction  of  a  nose  {Maiso7i7ieuve). — The  dotted  lines 
indicate  the  incisions  through  the  lip.  The  tissues  are  undercut  and  brought  forward,  the 
V  is  raised  and  the  incisions  are  sutured. 

line  is  loosened  and  brought  forward.  The  V-shaped  flap  is  then 
shifted  upward  to  form  the  columna.  The  lip  defect  is  closed.  Tubes 
are  placed  in  the  nostrils  until  healing  is  complete  (Fig.  548). 

The  result  can  be  improved  by  the  implantation  of  a  cartilaginous 
support,  and  a  secondary  operation  to  enlarge  the  nostrils. 


Pig.  549.— Operation  for  narrowing  and  lengthening  the  columna  (Gensoul). — -i.  The 
shaded  area  indicates  the  defect  left  by  e.xcising  an  ellipse  of  tissue.  The  solid  line  indicates 
the  incision.     2.  All  incisions  closed. 


Reduction  of  a  Thickened  Columna,  and  Advancing  the  Point  of  the 

Nose 

Gensoul's  Operation.— A   deep   incision  is   made   from   the  floor 
of  each  nostril  downward  and  inward,  the  two  meeting  at  a  point  just 


492 


PLASTIC    SURGERY 


below  the  union  of  the  septum  and  the  upper  lip  and  forming  a  V. 
The  tissues  are  loosened,  the  nose  is  drawn  forward,  and  the  wound  is 
sutured  in  the  shape  of  a  Y.  The  columna  itself  is  narrowed  by  the 
removal  of  an  elhpse  of  tissue  and  the  skin  is  sutured  (Fig.  549). 


12  3 

Fig.  550. — Operation  for  correcting  an  elongated  lobule  {Kolle). — The  scalpel  is  passed 
through  the  nose  at  the  point  E,  and  is  carried  down  through  the  tip.  From  E  to  G  the 
ala  on  each  side  is  trimmed.  From  C  to  E  the  septum  is  trimmed.  The  tip  B  of  the  flap 
A  is  cut  away  and  the  end  of  the  flap  A  is  sutured  to  C.  The  cartilage  of  the  ala  is  trimmed 
and  the  sulcus  is  closed. 

The  base  of  the  nose  is  sometimes  too  wide,  and  this  may  be  cor- 
rected by  the  removal  of  a  diamond-shaped  section  from  the  posterior 
rim  of  the  nares  (Kolle).  f  V  ^/ 


Fig.  551. — Operation  for  lengthening  the  columna  {Carter). — i.  The  dotted  line  shows 
the  inverted  Y-shaped  incision  which  divides  the  columnar  cartilage  and  is  continued 
under  the  floor  of  the  nostrils,  making  two  flaps,  A  and  B,  which  are  united  in  the  midline. 
2.  The  incisions  in  the  floor  are  then  extended  under  the  alae  liberating  them,  so  that  they 
can  be  brought  toward  the  midline,  thus  narrowing  and  lengthening  the  nose. 


The  Correction  of  Lobe  Defects 

Kolle's  Operation  for  Correction  of  Broad  Lobe.^ — A  diamond-shaped 
piece  of  tissue  is  removed  from  either  side  of  the  columna.  The  tissues 
are  loosened  and  the  wounds  are  sutured. 


SURGERY  OF  THE  EXTERNAL  NOSE  493 

An  elevated  lobe  may  be  lowered  by  removing  the  anterior  third  of 
the  columna,  with  a  triangular  section  of  the  cartilaginous  septum 
above  (Kolle). 

Bifid  Nose 

Bilid  nose  is  a  rare  congenital  deformity  in  which  the  two  halves 
of  the  nose  have  not  been  normally  joined  in  front.  A  long  vertical 
depression  remains  in  the  midline;  the  nose  is  broad,  and  double 
pointed. 

The  simplest  method  of  correcting  this  deformity  is  to  remove  an 
elliptic-shaped  piece  of  skin  and  underlying  tissue  (of  sufficient  size) 
from  the  depression  and  bring  the  edges  together. 


Fig.  552. — Operation  for  correcting  an  elevated  lobule  (Kolle). — i.  The  shaded  area 
and  dotted  lines  indicate  the  amount  of  septum  and  columna  to  be  removed.  2.  The 
lobule  restored  to  normal  and  the  edges  sutured. 


BIBLIOGRAPHY 

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"Ibid.,"  1917,  pp.  571,  S75,  1397. 
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CHAPTER  XX 

PLASTIC  SURGERY  OF  THE  JAWS,  LIPS  AND 

CHEEKS 

GENERAL  CONSIDERATIONS 

The  early  treatment  of  wounds  of  the  soft  parts  has  already  been 
considered  in  the  Section  on  the  Healing  of  Wounds.  Suffice  it  to 
repeat  here  that  when  there  is  bone  destruction,  early  suture  of  the 
soft  parts  is  indicated,  done  over  the  proper  prosthetic  apparatus  in 
order  to  prevent  shrinkage.  Nevertheless,  it  must  be  remembered 
that  when  this  closure  is  done  merely  for  its  own  sake,  and  at  the 
expense  of  future  function  of  the  jaws,  a  fundamental  principle  is 
violated.  Where  there  has  been  extensive  destruction  of  tissue,  the 
wounds  should  be  allowed  to  heal  firmly  before  shifting  flaps.  The 
flaps  should  be  planned  in  such  a  way  as  to  make  the  scars  of  the 
wounds  from  which  they  are  raised  as  inconspicuous  as  possible.  When 
feasible,  all  incisions  should  be  made  along  the  natural  folds,  or  under 
the  angle  of  the  jaw. 

In  cheek  or  lip  plastics  in  old  cases,  as  far  as  possible  scar  tissue 
should  be  excised  and  the  mucous  membrane  and  skin  surface  thor- 
oughly separated  down  to  normal  tissue.  In  closing  cheek  or  lip  wounds 
after  the  excision  of  scar  tissue,  or  in  any  operation  on  the  face  in  which 
tension  sutures  are  required,  the  buried  type  is  to  be  preferred.  Drain- 
age should  be  provided  whenever  necessary. 

After  operation  the  parts  should  be  immobilized  as  completely  as 
possible,  and  talking  should  be  discouraged.  Liquid  food  should 
be  administered  through  a  nasal  tube  to  avoid  soiling,  and  the  mouth 
must  be  kept  clean  with  irrigations,  which  should  be  most  carefully 
given. 

After  healing  has  taken  place,  and  the  defects  are  filled,  much  can 
be  done  to  improve  the  appearance  by  secondary  operations. 

In  shifting  a  flap  from  the  temple  a  part  may  be  of  hairless  and  a 
part  of  hairy  skin.  Advantage  may  be  taken  of  the  hairy  portion  in 
forming  an  upper  lip,  or  reconstructing  the  hairy  portion  of  the  cheek. 

An  important  preliminary  preparation  for  all  operations  on  the  jaw 

32  497 


498  PLASTIC    SURGERY 

and  cheek  or  lip  is  the  removal  of  decayed  teeth  and  stumps.  Not 
until  the  condition  of  the  mouth  is  satisfactory  should  the  operation  be 
performed. 

Anesthesia. — Much  can  be  done  under  local  anesthesia,  either  by 
nerve  blocking  or  infiltration.  Not  infrequently  an  operation  may  be 
started  under  a  general  and  finished  under  local  anesthesia,  or  vice 
versa.  If  a  general  anesthetic  is  used  it  should  be  given  through  nasal 
or  pharyngeal  tubes.  In  either,  in  order  to  obtain  a  relatively  clean 
field  for  operation  after  proper  disinfection  with  ether  and  one-third 
strength  tincture  of  iodin,  the  mouth  should  be  packed  with  dry  sterile 
gauze.  The  packing  has  the  additional  advantage  of  preventing  the 
aspiration  of  blood. 

In  those  cases  in  which  there  is  locking  of  the  jaws  especial  care 
must  be  taken  in  the  preliminary  preparation,  as  vomiting  may  be 
disastrous. 

Preparation. — Fresh  wounds  due  to  trauma  should  be  thoroughly 
washed  with  ether,  followed  by  one-third  strength  tincture  of  iodin. 
This  technic  is  also  satisfactory  in  the  mouth  and  on  the  cheek  and  lips. 
Every  effort  should  be  made  to  preserve  asepsis.  It  is  true  that  this 
is  extremely  difficult  in  operations  around  the  mouth,  but  no  relaxation 
in  technic  should  be  tolerated. 

SURGERY  OF  THE  JAWS 

In  reconstruction  of  the  jaws  our  principal  aim  is  to  rectify  defects 
in  the  framework  which  supports  the  overlying  soft  parts. 

In  civil  practice  the  plastic  surgeon  is  occasionally  called  upon  to 
correct  the  deformity  which  follows  removal  of  more  or  less  extensive 
sections  of  the  jaws  for  malignant  growths.  The  majority  of  these 
cases,  however,  are  referred  only  after  contracture  has  taken  place  and 
often  when  nearly  all  chance  of  obtaining  a  good  result  has  disappeared. 

The  great  number  of  war  wounds  of  the  jaws  in  the  last  four  years 
has  increased  the  interest  in  this  subject  and  many  advances  have  been 
made  in  the  methods  of  treatment.  I  wish  again  to  emphasize  the 
great  importance  of  a  close  and  early  cooperation  with  the  dental 
surgeon  in  dealing  with  loss  of  substance  in  the  jaws.  The  dental 
surgeon  should  be  responsible  for  constructing  and  placing  a  temporary 
prosthetic  apparatus  which  will  prevent  contracture  of  the  soft  parts, 
and  at  the  same  time  keep  the  fragments  in  position  until  the  gap  can 
be  filled  with  bone  or  cartilage;  or,  if  the  destruction  is  too  great  for 


OF    THE    JAWS.    LIPS    AND    CHEEKS  499 

plastic  help  he  should  institute  the  proper  permanent  prosthesis.  The 
plastic  surgeon  should  attend  to  the  transplantation  of  bone  and  the 
reconstruction  of  the  missing  soft  parts. 

Whenever  the  general  surgeon  undertakes  destructive  operations 
on  the  jaws  without  the  cooperation  of  the  dental  surgeon,  he  is  not 
giving  the  patient  the  benefit  of  the  best  treatment.  Nevertheless, 
strange  to  say,  before  this  war  this  was  seldom  done,  and  even  today 
some  surgeons  do  not  appreciate  the  importance  of  such  help. 

Recent  Injuries 

Ordinary  fractures  without  loss  of  substance  (or  with  only  a  small 
bony  loss  which  will  probably  regenerate)  are  of  no  particular  interest 
to  the  plastic  surgeon,  except  as  a  secondary  matter  in  connection  with 
extensive  destruction  of  soft  parts.  On  the  other  hand,  his  part  begins 
whenever  there  is  enough  destruction  of  bone  following  operation, 
disease  or  trauma,  to  call  for  reconstructive  work.  Associated  with 
the  loss  of  bone  there  is  usually  more  or  less  laceration  or  destruction 
of  the  cheeks  or  lips,  and  these  must  be  reconstructed  or  repaired  over 
the  proper  prosthetic  apparatus  to  preserve  the  desired  contour,  before 
we  proceed  to  bone  transplantation.  ^Moreover,  all  pathological  and 
inflammatory  conditions  should  be  cleared  up  and  sufficient  soft  parts 
be  provided  to  hold  the  transplant.  In  all  fractures  of  the  jaw.  with 
or  without  loss  of  substance,  early  splinting  is  essential,  and  if  there  is 
accompanying  laceration  or  destruction  of  the  soft  parts  early  closure 
(if  this  is  possible)  is  of  great  importance  in  order  to  avoid  subsequent 
contracture.  In  many  instances  of  extensive  loss  of  the  soft  parts,  skin 
and  mucous  membrane  may  be  sutured  together  temporarily,  because 
much  may  be  gained  by  this  maneuver  in  hastening  healing,  and  mini- 
mizing the  formation  of  scar  tissue.  Teeth  should  be  preserved,  even 
if  loosened,  and  all  bony  fragments,  which  are  not  obviously  useless, 
should  be  saved. 

Where  there  is  loss  of  bone  correct  alignment  is  of  the  greatest 
importance,  with  bony  union  if  feasible.  But  if  this  is  not  possible 
without  deformity,  the  alignment  should  be  maintained  by  means  of 
a  temporary  prosthetic  apparatus  until  the  gap  (if  not  too  large)  can 
be  filled  with  bone. 

The  ultimate  test  of  the  utility  of  any  method  of  reconstruction 
of  the  mandible  is  the  ability  of  the  patient  to  masticate  ordinary 
food.     As  has  been  demonstrated  clinically,  this  is  possible  provided 


500  PLASTIC    SURGERY 

the  occlusion  is  good,  even  if  the  union  is  not  perfectly  solid. 
Buried  prostheses  of  wire,  vulcanite,  and  other  materials,  have  been 
used  to  fill  defects  in  both  upper  and  lower  jaws,  but  their  use  is  not 
to  be  recommended.  Since  the  present  work  deals  with  plastic  surgery, 
I  shall  not  refer  to  the  various  methods  employed  in  plating,  wiring, 
or  splinting,  but  shall  describe  only  those  connected  with  the  use  of 
free  bone  grafts  and  pedunculated  flaps  with  attached  bone. 

EXTENSIVE  DESTRUCTION  OF  THE  MANDIBLE  AND  THE 

SOFT  PARTS 

In  a  recent  article  by  Kazanjian  and  Burrows,  in  speaking  of  war 
wounds  in  which  there  is  extensive  destruction  of  the  mandible  and  also 
of  the  soft  parts,  they  emphasize  the  fact  that  the  early  effort  of  the 
surgeon  must  be  directed  toward  treating  shock,  checking  hemorrhage, 
combating  infection,  removing  foreign  bodies,  fragments  of  bone  and 
soft  parts  which  are  without  vitality,  providing  drainage,  and  support- 
ing the  part.  Frequent  irrigation  and  changes  of  dressings  are  neces- 
sary. Traumatic  edema  of  the  tongue  and  glottis  may  occur  and  in 
extensive  wounds  the  support  of  the  tongue  may  have  been  destroyed, 
so  that,  unless  the  patient  is  kept  in  a  sitting  position  with  the  head 
forward,  the  tongue  will  drop  back  and  obstruct  the  breathing. 
Tracheotomy  should  be  done  at  once  if  the  sitting  position  does  not 
relieve  the  obstruction.  Unless  absolutely  necessary  a  general  anes- 
thetic should  not  be  given,  as  aspiration  pneumonia  may  occur.  When 
sloughs  and  sequestra  have  been  cast  off  and  the  granulations  begin 
to  be  healthy,  some  of  the  secondary  suturing  may  be  done. 

It  is  best  to  feed  the  patient  through  the  nares,  although  an  eso- 
phageal tube  may  sometimes  be  used.  As  soon  as  conditions  are  favor- 
able the  fragments  of  the  mandible  must  be  put  into  the  proper  position 
and  held  by  means  of  a  temporary  splint.  The  alignment  should  be 
directly  under  the  alveolar  ridges  of  the  upper  jaw,  and  sufficient  inter- 
maxillary space  should  be  allowed.  If  teeth  remain  on  the  fragments, 
the  splint  is  fastened  to  them;  if  no  teeth  are  present,  a  removable 
vulcanite  splint  is  made  to  fit  over  the  fragments. 

It  is  important  to  preserve  the  buccal  sulcus  if  it  still  remains. 
If  it  has  been  destroyed  the  mucous  membrane  should  be  divided  along 
its  attachment  to  the  alveolar  ridge,  a  deep  incision  made  along  the 
margin  of  the  jaw,  the  cut  mucous  membrane  edge  drawn  down  into 
this  with  sutures,  the  sulcus  reestablished  and  maintained  by  means 


OF    THE    JAWS,    LIPS    AND    CHEEKS  .  5OI 

of  flanges  attached  to  temporary  splints.  Before  the  soft  parts  are 
dosed  an  artihcial  jaw  of  normal  size,  made  of  vulcanite,  is  worn  for  a 
time;  then  the  plastic  closure  is  done,  and  still  later  a  permanent 
artificial  jaw  is  made. 

One  of  the  most  serious  complications  in  gunshot  wounds  of  the  face 
and  jaws  is  secondary  hemorrhage,  which  occurs  most  frequently 
between  the  fourth  and  twelfth  days,  but  has  been  reported  as  late  as 
the  forty-fifth  day  (Kazanjian  and  Burrows).  The  cause  of  the 
hemorrhage  is  usually  sepsis,  or  injury  to  the  vessel  by  foreign  bodies. 
It  is  treated  by  digital  pressure,  properly  applied  packing,  or  by  catch- 
ing and  ligating  the  bleeding  vessel.  Occasionally  it  becomes  neces- 
sary to  ligate  the  external  carotid  artery. 

RECOXSTRUCTIOX  OF  THE  SUPERIOR  MAXILLA 

As  a  rule  little  can  be  done  by  plastic  methods  to  reconstruct  the 
upper  jaw  after  loss  of  substance,  although  Morestin  has  been  able  in 
several  cases,  after  repair  of  the  soft  parts,  to  reconstruct  the  superior 
maxilla  partially  by  means  of  costal  cartilage.  The  deformity  due  to 
the  loss  of  bone  framework  can  be  much  improved,  however,  by  some 
prosthetic  apparatus  which  will  fill  out  the  buccal  depression,  separate 
the  nasal  from  the  oral  cavity,  and  restore  the  masticating  surface. 

RECOXSTRUCTIOX  OF  THE  MAXDIBLE 
(LOWER  JAW) 

The  reconstruction  of  defects  in  the  mandible  may  be  accomplished 
by  interposing  bone  or  cartilage  between  the  fragments.  There  are 
two  general  methods  of  filHng  the  gap:  (i)  By  the  free  transplantation 
of  bone  or  cartilage;  (2)  a,  by  the  transplantation  of  a  pedunculated  flap 
of  skin,  or  of  skin  and  muscle  from  which  the  bone  has  not  been  sepa- 
rated (usually  a  portion  of  the  clavicle) ;  b,  by  shifting  in  a  section  of 
bone  from  the  mandible  itself,  without  detaching  it  from  the  soft  parts. 
This  latter  method  cannot  be  used  in  large  defects. 

The  transplantation  of  bone  to  fill  a  deject  in  the  mandible  whether  free 
or  attached  to  a  peduncidated  flap,  must  not  be  undertaken  until  healing 
is  complete,  and  all  avoidable  chances  of  infection  have  been  eliminated. 
The  gap  should  not  be  filled  for  at  least  six  months;  a  still  longer  period 
must  elapse  before  the  final  result  can  be  determined. 

It  may  be  quite  difhcult  to  expose  the  mandible  fragments  with- 


502  PLASTIC    SURGERY 

out  opening  into  the  mouth,  and  if  this  should  occur  the  operation 
should  be  abandoned  temporarily.  Early  infection,  at  the  time  of 
operation,  will  usually  destroy  the  transplanted  bone  completely,  but 
if  the  gap  is  not  too  wide  sufficient  callus  may  form  to  bridge  the 
defect.  Late  infection  (after  several  weeks)  may  not  injure  the  graft, 
or  only  a  portion  of  it  may  slough.  Cartilage  will  be  found  much  more 
resistant  to  infection. 

If  the  gap  is  less  than  1.25  cm.  {}^  inch)  long,  union  by  natural 
growth  may  be  expected,  but  if  it  is  more  extensive,  bony  union  without 
interposition  of  bone  is  doubtful.  Defects  of  the  mandible  larger 
than  3.  to  3.5  cm.  (11:5  to  1%  inches)  should  be  repaired  with  free  bone 
grafts,  or  with  pedunculated  flaps  to  which  bone  is  attached.  The  loss 
of  nearly  all  of  the  horizontal  ramus  on  one  side  makes  the  utility  of 
bone  transplantation  somewhat  uncertain,  although  some  good  results 
have  been  reported  after  even  greater  destruction;  in  these  cases  the  use 
of  a  permanent  prosthetic  apparatus  has  to  be  considered. 

When  bone  or  cartilage  is  transplanted,  immobilization  of  the 
mandible  and  the  transplant  is  important.  This  is  usually  accom- 
plished by  some  apparatus  that  will  fix  the  lower  teeth  to  the  upper, 
but  the  fixatian  may  also  be  in  the  "open  bite"  position  to  avoid  con- 
striction. The  bone  grafts  may  be  secured  with  plates,  by  wiring, 
or  by  forcing  the  ends  of  the  graft  into  slots  cut  in  the  mandibular 
fragments. 

The  Use  of  Bone  or  Cartilage  Grafts. — Gallic  and  Robertson's 
operation  for  the  transplantation  of  free  bone  to  fill  defects  in  the 
mandible  is  simple  and  satisfactory.  They  report  good  results  in 
filling  gaps  from  2.5  to  5.  cm.  (i  to  2  inches)  in  length.  The  fragments 
are  exposed  by  an  incision  along  the  lower  border  of  the  jaw.  Then 
with  a  motor  saw  a  cut  is  made  1.25  cm.  (1^  inch)  deep  and  from  2.5 
to  5.  cm.  (i  to  2  inches)  long,  along  the  inferior  border  of  each  fragment. 
Care  should  be  taken  not  to  open  into  the  mouth,  or  into  a  tooth  socket. 
With  an  osteotome  the  saw  cuts  are  spread  apart,  and  a  wedge-shaped 
gap  is  made  in  each  fragment  for  the  reception  of  the  graft.  An 
interdental  splint  which  has  been  previously  connected  to  the  teeth  of 
both  jaws  is  now  locked,  with  the  teeth  in  exactly  the  correct  relation  to 
each  other,  and  this  is  used  throughout  the  treatment.  Seven  and 
a  half  centimeters  (3  inches)  or  more  of  bony  rib  is  removed  and  the 
rib  is  spht  lengthways  on  the  flat.  Half  of  the  piece  is  then  forced  into 
the  prepared  slots,  the  smooth  side  being  toward  the  mouth,  while 
the  other  half  of  the  graft  (smooth  side  out)  is  shortened  and  placed 


OF    THE    JAWS,    LIPS    AND    CHEEKS 


503 


between  the  fragments  on  the  exposed  surface  of  the  piece  of  rib  wedged 
into  the  slots.  The  whole  is  secured  with  kangaroo  tendons  passed 
through  drill-holes,  and  the  soft  parts  are  closed  (Fig.  553-554). 

Cole   transplanted  free  bone  after  preparing  a  bed  for  it.     After 
placing  a  section  of  decalcitied  bone  between  the  fragments  and  allow- 


FiG.  553. — Method  of  closing  a  gap  in  the  mandible  with  free  bone  grafts  {Gallie  and 
Robertson). — i.  The  dotted  lines  indicate  the  slots  made  with  the  motor  saw.  2.  The 
split  half  of  the  rib  with  smooth  surface  toward  the  mouth  cavity  is  placed  in  the  slots 
which  have  been  widened  with  the  osteotome. 

ing  it  to  remain  for  three  months,  he  removes  it  and  implants  a  free 
graft  from  the  rib  or  tibia,  which  he  secures  to  the  fragments  with 
silver  plates.  (The  bed  into  which  the  graft  is  to  be  eventually  placed 
has  also  been  formed  by  implanting  temporarily,  pieces  of  celluloid, 
vulcanite,  or  metal.)     Cole  has  successfully  filled  defects  varying  from 


Fig.  554. — GaUie  and  Robertson's  method,  continued.— X  portion  of  the  other  half 
of  the  rib  is  placed  between  the  ends  of  the  fragments  in  contact  with  the  first  half,  smooth 
surface  outward,  and  all  are  secured  by  kangaroo  tendon  sutures. 

2.5  to  7.5  cm.   (i   to  3  inches),  and  says  he   has   had    70    per   cent, 
of  successes. 

Morestin  has  used  shaped  pieces  of  free  cartilage  to  fill  defects 
in  the  mandible.  He  has  found  that  with  the  cartilage  he  can  restore 
the  contour  and  prevent  recurrence  of  the  deformity,  and  in  addition 


504 


PLASTIC    SURGERY 


can  obtain  good  functional  results,  although  the  union  between  cartilage 
and  bone  is  not  perfectly  rigid. 

The  Use  of  Pedunculated  Flaps  with  Bone  Attached. — Peunculated 
flaps  from  the  neck  or  chest  to  which  are  attached  bone  from  the  clavicle, 
have  been  used  to  close  defects  in  the  mandible.  These  flaps  may  be 
composed  of  skin  and  bone,  or  skin  muscle  and  bone.  The  operative 
procedure  is  extensive  and  causes  a  good  deal  of  mutilation  and  much 
subsequent  scarring.  In  certain  cases  which  call  for  a  long  piece 
of  bone  not  detached  from  its  overlying  soft  parts,  this  method  is  of 
value  (Fig.  555). 

My  experience  has  shown  it  to  be  poor  surgery  to  attempt  the  repair 
of  the  mandible  and  the  soft  parts  at  the  same  time.     The  soft  parts 


Fig.  555. — Method  of  closing  a  defect  in  the  mandible  and  reconstruction  of  the  lower 
lip  at  the  same  time  {Blair). — i.  The  dotted  line  indicates  the  proposed  flap.  A  section 
of  bony  rib  has  been  previously  transplanted  between  the  skin  and  the  platysma  muscle. 
2.  The  flap  raised,  the  bone  being  grasped  in  forceps  to  avoid  displacing  it.  3.  The  flap 
in  position.  The  bone  has  been  wired  into  the  defect  in  the  mandible.  The  end  of  the 
skin  flap  is  turned  over  to  line  the  lip.  This  operation  may  be  modified  by  using  a  section 
of  the  clavicle.  On  the  cadaver  the  method  is  admirable,  but  in  actual  practice  it  is  with- 
out value. 


should  be  reconstructed  first  over  the  proper  prosthetic  apparatus, 
and  only  after  healing  is  complete,  and  after  a  considerable  period  of 
time  has  elapsed,  should  the  defect  in  the  mandible  be  filled.  It  is 
true  that  this  procedure  appears  to  take  much  longer,  but  in  the  end 
time  will  be  saved.  In  this  type  of  work  there  is  no  short  cut  to  success. 
If  a  pedunculated  flap  with  a  portion  of  the  clavicle  attached  is 
used,  the  bone  should  be  implanted  between  the  fragments  with  exactly 
the  same  precautions  as  when  a  bone  graft  is  transplanted,  and  should 
there  be  accidental  opening  into  the  mouth  cavity  the  operation  should 
be  postponed.  The  bone  may  be  implanted  in  adjacent  soft  parts 
for  several  weeks  (Imbert  and  Real)  and  then  shifted  in,  the  soft  parts 


OF    THE    JAWS,    LIPS    AND    CHEEKS 


505 


being  utilized  as  a  pedicle.  This  method  has  little  to  recommend  it, 
for  unless  the  transplantation  is  done  within  three  weeks,  absorption 
of  the  bone  will  begin  and  continue  until  the  bone  eventually  disappears. 
On  the  other  hand,  this  procedure  can  be  successfully  carried  out  with 
cartilage,  which  will  not  change  in  size;  hence  in  certain  cases  it  maybe 
the  method  of  choice. 

Pedunculated  Flap  from  the  Mandible. — Cavalie,  Cole,  Esser,  and 
others,  have  used  pedunculated  flaps  from  the  mandible  itself.  Cole's 
method  is  simple  and  efficient,  and  an  outline  of  his  technic  follows: 
A  wide  skin  flap  extending  from  the  symphysis  to  the  angle  of  the  jaw 
is  raised  from  the  neck  to  the  desired  level.     The  posterior  fragment  is 


I  2  3 

Fig.  556. — Method  of  repairing  a  defect  in  the  mandible  with  a  pedunculated  bone  flap 
{Cole). — I.  The  posterior  fragment  exposed  and  freshened.  An  incision  is  made  through 
the  soft  parts  over  the  outer  aspect  of  the  anterior  fragment,  and  then  through  this  incision 
with  a  saw  a  fragment  is  loosened.  2.  The  bone  fragment  attached  to  the  soft  parts  as  a 
pedicle.  3.  Wire  sutures  in  place  which  will  draw  the  flap  of  bone  and  soft  parts  into 
position. 


thoroughly  exposed,  but  only  enough  of  the  anterior  fragment  to 
show  the  width  of  the  defect.  A  horizontal  incision  is  made  through 
the  soft  parts  covering  the  outer  aspect  of  the  anterior  fragment  at  a 
level  immediately  below  the  buccal  sulcus.  The  basal  margin  of  this 
portion  of  the  jaw  is  then  sawn  off  through  the  incision  mentioned 
above.  The  periosteum  on  the  inner  aspect  is  then  divided  and  lateral 
incisions  through  the  platysma  and  deep  fascia  are  made  to  form  the 
pedicle  which  is  loosened.  If  necessary  the  bone  flap  may  be  obtained 
from  the  mandible  on  the  other  side,  the  anterior  belly  of  the  digastric 
muscle  being  used  as  a  pedicle.  The  ends  of  the  mandibular  fragments 
are  freshened  and  the  flap  is  shifted  into  the  defect  and  secured  with 
silver  wire,  which  passes  through  the  fragments  through  the  pedicle  and 
around  the  transplant.  Drainage  is  provided  and  the  soft  parts  are 
closed  (Fig.  556). 

Cole's  experience  has  led  him  to  prefer  this  method  instead  of  free 


5o6  PLASTIC    SURGERY 

bone  grafts  in  all  cases  in  which  the  gap  is  not  over  3.  cm.  {i}^  inches) 
wide.  He  suggests  the  use  of  bilateral  pedunculated  flaps  for  repair 
of  the  symphysis. 

.  This,  or  some  similar  method  of  using  a  flap  from  the  jaw  has 
much  to  commend  it.  It  is  a  simple  procedure  as  far  as  manipulation 
is  concerned,  the  circulation  in  the  bone  is  assured,  and  the  results  are 
more  promising  than  with  free  grafts. 

Irregularities  of  the  Mandible. — We  often  see  a  quite  marked  bulg- 
ing or  a  depression  of  a  portion  of  the  lower  jaw  without  interference 
with  function.  It  is  possible  to  remove  the  prominent  area  by  chiseling 
off  the  bone.  Depressions  may  be  obliterated  by  placing  properly 
shaped  pieces  of  cartilage  in  the  defect,  and  securing  it  to  the  bone. 
The  periosteum  may,  or  may  not  be  opened  according  to  the  necessities 
of  the  operation.  The  incisions  for  both  of  these  procedures  should 
be  made  under  the  angle  of  the  jaw. 

CONSTRICTION  OF  THE  JAW 

Trismus. — Many  cases  of  trismus  of  the  muscles  of  mastication 
have  been  found  following  fractures  (with  or  without  loss  of  substance), 
or  slight  wounds  of  the  soft  parts.  Much  can  be  done  to  avoid  this 
condition  by  the  use  of  the  "open  bite"  splint.  Trismus  may  be 
successfully  treated  by  gradual  continuous  stretching  of  the  muscles. 

Sclerosis  of  the  Muscles. — In  other  cases  the  presence  of  a  sclerosis 
of  the  muscles  of  mastication  renders  stretching  practically  useless. 
We  often  find  this  type  in  old  cheek  or  lip  defects,  due  to  ulceration  or 
infection,  and  in  these  the  operation  of  Le  Dentu,  so  successfully  used 
by  Morestin,  is  of  great  value.  The  procedure  is  as  follows:  An 
incision,  3.  cm.  {i}"^  inches)  long,  is  made  behind  the  angle  of  the  jaw. 
The  insertions  of  the  masseter  and  internal  pterygoid  muscles  are 
exposed,  and  with  a  knife  and  elevator  loosened  from  the  mandible. 
The  wound  is  then  sutured.  In  this  way  the  constriction  is  relieved, 
and  the  jaw  is  opened  widely  and  braced  with  a  wedge  for  three  days. 
One  or  both  sides  may  be  treated,  as  may  be  necessary.  A  few  days 
later  the  patient  is  able  to  masticate  without  difficulty. 

The  treatment  of  anchylosis  of  the  jaw  caused  by  involvement  of 
the  joint  is  essentially  an  orthopedic  problem,  and  will  not  be  considered 
here.  I  might  say,  however,  that  excision  of  the  condyle  with  a  portion 
of  its  neck  is  the  best  procedure. 


OF    THE    JAWS,    LIPS    AND    CHEEKS  507 

RECONSTRUCTION  OF  THE  ORBITAL  RIM  AND  THE  MALAR 
BONE  FOLLOWING  INJURY 

Occasionally  in  civil  practice,  and  often  in  the  injuries  of  war,  the 
plastic  surgeon  is  called  upon  to  correct  deformities  following  the  de- 
struction of  the  malar  bone  and  the  various  portions  of  the  orbital  margin .  ^ 
The  absence  of  the  bony  framework  causes  a  deep  depression,  which 
cannot  be  corrected  unless  the  framework  is  reconstructed.  Accom- 
panying these  depressions  there  is  usually  extensive  deep-seated  scarrins; 
and  great  deformity.  Not  uncommonly  the  eye  and  one  or  both  lids 
are  destroyed. 

Morestin  has  been  able  to  reconstruct  the  framework  by  the  implan- 
tation of  either  auto  or  isocartilage,  usually  taken  from  the  sixth  and 
seventh  cartilaginous  ribs. 

The  scar  tissue  is  removed  by  gradual  excision  and  healthy  tissue 
is  brought  in  from  the  edges.  The  lids,  if  any  remain,  are  repaired 
and  adjusted,  or  may  be  reconstructed.  After  this  has  been  accom- 
plished, the  bone  defect  is  exposed  and  the  cartilage  is  shaped  to  fill 
the  defect. 

It  is  difficult  to  fasten  the  shaped  cartilage  securely  to  the  bone 
(there  is  never  rigid  union  between  bone  and  cartilage),  but  much  can 
be  accomplished  by  mortising  the  edges  and  by  utilizing  any  means 
which  seems  available  for  the  particular  case.  I  have  found,  experi- 
mentally, that  sutures  should  not  be  put  through  the  cartilage  itself,  as 
they  tend  to  cause  a  fracture  at  that  point,  but  may  very  well  be 
inserted  through  the  perichondrium. 

A  cuff  of  fascia  lata  may  be  sutured  snugly  around  the  opposed  or 
mortised  ends  in  certain  situations. 

The  contour  of  the  normal  side  of  the  face  should  be  reproduced  as 
perfectly  as  possible.  The  soft  parts  are  then  closed  over  the  cartilage 
inserts.  All  portions  of  the  orbit  may  be  reconstructed  in  this  manner. 
In  certain  cases  free  fat  grafts  may  be  used  in  conjunction  with  the 
cartilage  with  excellent  results. 

DEPRESSED  FRACTURES  OF  THE  M.ALAR  BONE 

At  times  depressed  fractures  of  the  malar  bone  cause  great  deformity 
of  the  cheek.     If  the  injury  is  old.  then  considerable  difficulty  may  be 

^  When  excising  the  superior  maxilla,  if  it  is  possible,  the  floor  of  the  orbit  should  be  pre- 
served by  some  such  method  as  that  described  by  Van  Hook,  as  in  this  way  sagging  of  the 
eye-ball  is  prevented,  and  repair  of  defects  in  this  portion  of  the  cheek  is  much  simplified. 


5o8  PLASTIC    SURGERY 

experienced  in  bringing  the  fragments  into  proper  position,  and  it  may 
be  necessary  to  expose  the  bone  through  a  skin  incision.  Before  this 
is  done,  however,  the  attempt  should  be  made  to  elevate  the  bone  by 
means  of  a  pair  of  "cow  horn"  dental  forceps,  which  grasp  the  bone 
through  the  skin,  as  suggested  by  Manwaring.  A  good  grip  of  the  bone 
can  be  obtained  by  placing  one  point  of  the  forceps  over  the  orbital 
ridge,  and  the  other  under  the  margin  of  the  body  of  the  bone  at  its 
outer  side,  and  there  is  little  or  no  scarring  of  the  skin. 

BIBLIOGRAPHY 

'Abstracts  of  War  Surgery",  1918,  p.  398. 

Blair,  V.  P.     "Surg.,  Gyne.  &  Obst.,"  Oct.,  1914,  436. 

"Surgery  and  Diseases  of  the  Mouth  and  Jaws,"  3d  Edition. 
Brophy,  T.  W.     "  Oral  Surgery." 
Brown,  Geo.  V.  I.     "Oral  Diseases  and  Malformations,"  2d  Ed.,  1917. 

Cavalie.     "Bull,  et  mem.  Soc.  de  med.  et  Chir.  de  Bordeaux,'  191 7,  93. 
CoDMAN.     "Boston  Med.  &  Surg.  Jour.,"  April  21,  1910,  532. 
Cole,  P.  P.  &  Btibb,  C.  H.     "Brit.  Med.  Jour.,"  1916,  i,  268 

"Brit.  Med.  Jour.,"  Jan.  18,  1919,  67. 
Cole,  P.  P.     "Lancet."    London,  March  17,  1917,  415. 

"Lancet."     London,  March  30,  1918,  459. 

"Brit.  Med.  Jour.,"  May  18,  1918,  565. 

"Brit.  Jour.  Surg.,"  July,  1918,  57. 

EssER,  J.  F.  S.     "Amer.  Jour.  Surg.,"  Dec,  191 7,  305. 
Eve,  F.     "Practitioner."    London,  May,  1916,  447. 

Gallie,  W.  E.  &  Robertson,  D.  E.     "Jour.  Amer.  Med.  Assn.,"  April  20,  1918,  1134. 
Gillies,  H.  D.  &  King,  L.  A.  B.     "Lancet."    London,  March  17,  1917,  412. 

V.  Hacker.     "Beitrage  z.  klin.  Chir.,"  1915-16,  Bd.  98,  289. 
Henderson,  M.  S.     "Surg.,  Gyne.  &  Obst,"  Nov.,  1918,  451. 

Imbert  &  Real.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1915,  21 21. 

"Lyon  Chir.,"  July-Aug.,  1918,  385. 
Ivy,  R.  H.     "Internat.  Abst.  Surg.,"  1918,  xxvii,  loi.     (Extensive  bibliography.) 

Kazanjian,  V.  H.  &  Burrows,  H.     "Brit.  Jour.  Surg.,"  July,  191 7,  126. 

"Brit.  Jour.  Surg.,"  July,  1918,  74. 
Kornew,  p.     "Beitrage  z.  klin.  Chir.,"  1914,  xciii,  62. 

Leonhard,  J.  V.  D.  H.     "Jour.  Laryngol.,  Rhinol.  and  Otology,"  Nov.,  1913,  582. 
LiLiENTHAL,  H.     "Anns.  Surg.,"  Aug.,  1911,  145. 
Loos,  O.     "Beitrage  z.  klin.  Chir.,"  1915-16,  Bd.  98,  73. 

McWiLLiAMS,  C.  A.     "Anns.  Surg.,"  March,  191 7,  283. 

Martinier,  p.  &  Lemerle,   G.     "  Injuries  of  the  Face  and  Jaw,  and  Their  Repair." 
(Translated  by  G.  H.  Whale,  1918.) 


OF    THE    JAWS,    LIPS    AND    CHEEKS  509 

MoRESTiN,  H.     "Bull,  et  mem.  de  la  Soc.  de  Chir.  dc  Par.,"  1915,  pp.  225,  314,  655,  667, 
1314,  2418,  2459. 

"Ibid.,"  1916,  2408. 

"Ibid.,"  1918,  1466. 
MoszKOwicz,  L.     "Archiv  f.  klin.  Chir.,"  cviii,  216. 
Mummery,  S.  P.     "Practitioner."     London,  Jan.,  1916,  73. 
MuNBY,  W.  M.  &  Forty,  A.  A.,  &  Shefford,  A.  D.     "Brit.  Jour.  Surg.,"  July,  1918, 

86. 
Murphy,  J.  B.     "Surgical  Clinics."     Chic,  1916,  pp.  569,  855. 
Murphy,  J.  B.  &  Kreuscher,  P.  H.     "Dental  Cosmos."     Philadelphia,  1916,  Iviii,  160. 

Nystrom,  G.     "Archiv  f.  klin.  Chir.,"  1912,  loor. 

Payr.     "Zent.  f.  Chir.,"  Sept.  5,  1908,  1065. 

Phemister,  D.  B.     "Surgical  Clinics."     Chicago,  April,  1918,  241. 

PiCKERiLL,  H.  P.     "Lancet."     London,  Sept.  7,  1918,  313. 

Pierre-Robin.     "Presse  med."     Paris,  Jan.  18,  191 7,  35. 

Pilcher  &  Oser.     "Archiv  f.  klin.  Chir.,"  191 2,  xci.x,  Nr.  4. 

Platt,   H.   &    Campion,  G.  G.  &  Rod\v.a.y,  B.  J.     "Lancet."     London,  March  30,  1918, 

461. 
Pont,  A.     "Lyon  Chir.,"  Dec,  1915,  No.  6. 

Roberts,  J.  B.     "New  York  Med.  Jour.,"  1918,  cvii,  668. 

"Anns.  Surg.,"  Sept.,  1918,  245. 
RoCKEY,  A.  E.     "Jour.  Amer.  Med.  Assn.,"  July  20,  1918,  183. 
Rydygier,  V.     "Zent.  f.  Chir.,"  Nov.  7,  1908,  1321. 

ScHWENK,  P.  N.  K.  &  Posey,  W.  C.     "Arch.  Ophth.,"  1918,  xlvii,  576. 
Sebile.\u,  p.     "Bull,  et  mem.  soc.  de  Chir.  de  Par.,"  1916,  2420. 
SoucHON,  E.     "Surg.,  Gyne.  &  Obst.,"  Aug.,  1911,  169. 
Stillman,  S.     "Anns.  Surg.,"  Jul}',  191 2,  70. 
Todd,  T.  W.     "Anns.  Surg.,"  April,  191 8,  403. 
Trotter,  W.     "Brit.  Med.  Jour.,"  Jan.  12,  1918,  49. 

V.\ladier,  A.  C.     "Brit.  Jour.  Surg.,"  July,  1916,  64. 
VAL.4.DIER  &  WH.A.LE.     "Brit.  Jour.  Surg.,"  July,  1917,  151. 
Voeckler,  Th.     "Deutsche  Zeitschr.  f.  Chir.,"  Feb.,  1918,  298. 


CHAPTER  XXI 
SURGERY  OF  THE  LIPS   (CHEILOPLASTY) 

General  Considerations. — Defects  or  other  deformities  of  the  lips 
cahing  for  plastic  surgery  may  be  due  to  congenital  malformations, 
trauma,  ulceration  (syphilis,  etc.j ;  very  frequently  to  burns  and  to 
the  excision  of  growths.  Except  for  harelip,  which  has  been  previously 
considered,  plastic  operations  on  the  lower  lip  are  required  much  more 
frequently  than  on  the  upper. 

In  reparatory  operations  on  the  lips  we  endeavor  to  construct  a 
mouth  of  proper  size  which  can  be  opened  and  closed  without  difhcultv. 
The  lips  must  he  lined  u'ith  mucous  membrane  or  skin,  to  avoid  subsequent 
contracture;  they  should  be  of  normal  shape  and  have  a  vermiKon 
border.  The  lower  lip  should  be  sufficiently  high  to  cover  the  teeth  in 
order  to  avoid  drooling  and  the  escape  of  food  during  mastication. 

Any  portion  of  either  lip  may  be  destroyed  or  distorted,  or  both  lips 
may  be  implicated  and  call  for  reconstruction  separately,  or  at  the  same 
time. 

It  is  very  important  that  the  vermilion  border  be  restored  because 
the  lip  will  then  be  much  more  flexible  and  the,  appearance  much  im- 
proved. The  vermilion  border  is  A^ery  extensible,  and  even  if  only 
a  small  portion  remains,  by  stretching  and  shifting  it  can  be  made  to 
form  the  border  of  the  new  lip.  It  has  been  suggested  that  a  vermilion 
border  be  tattooed  on  the  skin,  but  this  expedient  will  furnish  only  a 
poor  substitute  for  an  edge  consisting  of  mucous  membrane.  Hence 
the  method  should  be  discouraged. 

The  elasticity  and  stretching  capacity  of  tissues  around  the  mouth 
is  remarkable,  and  to  this  we  owe  our  ability  to  carry  out  some  of  the 
most  common  procedures.  One-half  and  possibly  a  little  more  of  the 
lower  lip  may  be  excised  without  excessive  narrowing  of  the  buccal 
orifice. 

As  far  as  possible  incisions  should  be  made  to  follow  the  natural 
lines  of  the  face,  and  the  flaps  planned  so  that  distortion  and  asym- 
metry will  be  avoided.  It  is  especially  important  that  the  commissures 
should  be  lined  with  mucous  membrane,  and  that  mucous  membrane 
should  be  sutured  to  the  skin  in  the  formation  of  the  new  lip,  for  if 

510 


SURGERY    OF    THE    LIPS 


511 


(his  can  be  done,  cicatricial  contracture  is  prevented,  and  much  sub- 
sequent discomfort  avoided. 

In  all  of  these  operations  in  which  flaps  through  the  full  thickness 
of  the  cheek  are  used  the  mucous  membrane  should  be  divided  about 
I.  cm.  (-5  inch)  above  the  skin  incision,  thus  giving  a  flap  which  can 
be  sutured  to  the  skin  to  form  the  new  vermilion  border.  In  planning 
flaps  to  reconstruct  a  lip  they  should  be  wide  enough  to  cover  the 
teeth,  and  long  enough  to  be  sutured  into  position  without  tension. 

In  the  restoration  of  the  lips  three  methods  may  be  used  either  alone 
or  in  combination,  (i)  By  simple  gliding  with  traction  of  the  pedicle 
(French  method);  (2)  by  a  flap  from  neighboring  tissue  with  more  or 
less  twisting  of  the  pedicle  (Indian  method) ;  (3)  by  a  flap  from  distant 
parts  (Italian  method). 


Fig.  557. — Hemangioma  involving  the  vermilion  border  of  the  lower  lip  and  the  mucosa 
lining  the  lip. — i.  Before  operation.  2.  After  operation.  An  elongated  ellipse  of  tissue 
was  removed  parallel  to  the  length  of  the  lip,  and  then  a  broad  V-shaped  area  was  removed. 
extending  from  the  first  defect  to  the  gingivolabial  fold.  The  edges  were  then  sutured. 
No  recurrence  has  followed. 


In  addition,  skin  grafting  is  often  used  to  cover  the  raw  surface 
after  the  correction  of  ectropion,  but  the  results  are  seldom  as  satis- 
factory as  when  more  radical  procedures  are  employed. 

The  restoration  may  be  done  immediately,  or  after  healing  has  taken 
place. 

Immediate  Restoration. — Defects  following  operative  procedures 
should  be  repaired  at  once  whether  on  the  upper  or  on  the  lower  lip, 
and  repair  should  ordinarily  be  undertaken  immediately  in  wounds  in 
which  there  has  been  loss  of  tissue.  In  these  cases  the  surgeon  deals 
with  normal  tissues. 

Secondary  Restoration. — By  secondary  restoration  is  meant  the 
repair  of  defects  after  the  edges  have  completely  healed.  These  defects 
may  follow  the  excision  of  tumors  in  which  immediate  restoration  was 
considered  inadvisable,  destruction  following  burns,  and  destructive 


512 


PLASTIC    SURGERY 


ulceration  of  various  kinds.  Many  of  the  operations  described  under 
immediate  restoration  of  both  the  upper  and  lower  lip  may  be  utilized 
after  excision  of  the  scar  tissue  edges. 


Fig.  558. — Contracture  of  the  face  following  a  burn.  Duration  eight  years. — i,  2  and 
3.  Profile  view  and  front  views  of  the  patient.  Note  the  ectropion  of  the  lids,  the  inability 
to  close  the  mouth  and  the  general  involvement  of  the  entire  face  with  scar  tissue. 


Fig.  559. — Contracture  of  the  face  following  a  burn,  continued. — i,  2  and  3.  Profile 
and  front  viev.^s  of  the  same  patient  after  numerous  operations  in  which  one  or  two  whole- 
thickness  grafts  were  used  around  the  eyes,  but  elsewhere  the  improvement  was  made  en- 
tirely by  shifting  flaps  of  scar  tissue,  sometimes  only  a  fraction  of  an  inch  at  a  time.  Note 
that  the  eyes  can  be  closed.  The  lips  can  be  brought  together  normally,  and  the  principal 
lines  of  tension  have  been  relieved. 


I  shall  discuss  the  operation  for  malignant  growths  of  the  lip  only 
from  the  standpoint  of  repair.     I  might  say,  however,  that  in  every 


SURGERY    OF    THE    LIPS  513 

case  of  this  type  a  wide  margin  should  be  allowed,  and  the  shape  of  the 
excised  area  should  be  as  uncomplicated  as  possible. 

Ordinarily  the  glands  in  the  neck  are  removed  through  incisions 
which  are  independent  of  those  used  for  closure  of  the  lip,  but  opera- 
tions have  been  devised  in  which  the  glands  may  be  removed  <^hrough 
the  same  incisions.  The  advantage,  of  course,  is  obvious;  there  are 
fewer  scars  and  the  exposure  is  much  better  when  a  large  flap  is 
reflected. 

The  deformities  and  defects  of  the  lips  vary  so  much  in  situation, 
shape  and  extent  that  a  great  many  operations  have  been  devised  for 
their  correction,  many  of  these  differing  only  in  detail. 

RESTORATION  OF  THE  UPPER  LIP 

Immediate  Reconstruction. — The  upper  lip  is  the  seat  of  malignant 
disease  much  more  rarely  than  the  lower,  so  that  restoration  following 
excision  is  less  frequently  required.  In  war  wounds,  however,  many 
reconstructive  operations  on  the  upper  lip  have  been  necessary. 

For  partial  loss  of  substance  unilateral  or  bilateral  flaps  may  be 
used.  If  the  defect  has  the  inverted  V-shape,  it  can  be  corrected  by 
suturing  the  edges  at  once,  or  later  by  freshening  the  edges  and  suturing. 
In  wounds  due  to  trauma  in  which  it  is  deemed  advisable  to  delay 
closure,  the  mucosa  and  skin  should  be  sutured  together  and  the  repair 
postponed  for  a  time,  after  which  a  modified  harelip  operation  may  be 
performed.  For  partial  defects  some  have  employed  unilateral  flaps 
with  a  lateral  pedicle,  as  in  the  operation  of  Blasius  who  utilizes  the 
portion  of  the  lip  above  the  defect  and  the  adjacent  tissues  of  the  cheek. 
Unfortunately  after  this  procedure  the  direction  of  the  pull  on  the  result- 
ing scar  is  across  the  natural  folds.  Flaps  from  the  lower  lip  have  also 
been  used  (the  reverse  of  Estlander's  operation  for  the  repair  of  the 
lower  lip)  but  the  method  is  inadvisable  on  account  of  the  pre- 
carious blood  supply.  In  any  case,  even  if  the  flap  lives,  the  result  is 
asymmetrical. 

In  cases  in  which  the  outer  portions  of  the  lip  below  the  alie  are  not 
destroyed,  Dieffenbach's  operation  may  be  used  for  either  immediate, 
or  secondary  repair.  A  vertical  incision  is  made  in  the  midline. 
Beginning  from  the  upper  end  of  this,  an  incision  is  made  on  each  side 
curving  upward  and  outward  around  the  alas,  through  the  full  thickness 
of  the  cheek.  The  tissues  on  the  sides  of  the  defect  are  shifted  down- 
ward to  form  the  free  border  of  the  lip,  and  the  points  which  are  below 
33 


514 


PLASTIC    SURGERY 


the  alas  are  sutured  in  the  midline.  Teale's  operation  is  somewhat 
similar,  and  Lexer  has  modified  it  in  order  to  give  more  freedom  to  the 
flaps  by  making  horizontal  incisions  extending  outward  from  the  upper 
end  of  the  incisions  curving  around  the  alae. 

The  disadvantage  of  these  operations  is  that  in  many  instances  the 
lip  is  contracted,  and  the  nostrils  may  be  nearly  closed.     It  is  well  to 


Fig.    560. — Operation  for  the  partial  reconstruction   of  the  upper  lip    (Blasius). — i   and 
2.   The  flap  X  is  shifted  downward  and  inward,  the  lines  CD  and  AB  being  sutured. 

bear  the  method  in  mind,  however,  as  occasionally  in  harelip  with  a 
wide  gap  and  very  scant  tissue  some  such  method  of  relaxation  may  be 
necessary  in  order  to  make  a  closure. 

Complete  Loss  or  Substance. — Many  of  the  methods  which  will 
be  described  for  restoration  of  the  lower  lip  cannot  be  employed  for  the 


.^ 


Fig.  561.  Fig.  562. 

Fig.  561. — operation  for  the  reconstruction  of  the  upper  lip  (Dieffenbach). — The  dark 
lines  indicate  the  incisions.  The  flaps  are  loosened  and  shifted  inward,  being  sutured  in 
the  midline. 

Fig.  562. — Operation  for  the  reconstruction  of  the  upper  lip  (Lexer). — The  dark  lines 
indicate  the  incisions.  The  transverse  incisions  give  more  freedom  in  shifting  the  flaps  than 
is  found  possible  in  Dieffenbach's  operation. 

upper  lip  for  the  reason  that  injury  to  the  facial  nerve  and  Stenson's 
duct  would  follow,  and  the  nostrils  would  also  be  encroached  upon. 

Bilateral  flaps  with  lateral  pedicles  have  been  used  by 
Lisfranc,  who  formed  quadrilateral  flaps  by  making  horizontal  inci- 
sions, the  upper  being  on  the  level  of  the  nostril,  and  the  lower  continu- 
ous with  the  commissures.  The  procedure  is  inadvisable  for  complete, 
although  it  may  be  used  in  selected  cases  for  partial  restoration. 


SURGERY    OF    THE    LIPS 


DI5 


Burow,  and  C.  Bernard's  modification  of  Lisfranc's  method  consists 
in  the  excision  of  four  triangles  of  normal  tissue,  in  order  to  remove 
redundant  tissue  and  to  facilitate  the  shifting  of  the  flaps. 


Fig.  563. — Operation  for  closing  a  defect  in  the  upper  lip  (Grant). — The  growth  is 
excised  and  lateral  flaps  are  made  through  the  full  thickness  of  the  lip.  They  are  shifted 
inward  and  sutured. 


Fig.  564.  Fig.  565. 

Fig.  564. — Operation  for  the  reconstruction  of  the  upper  lip  (Lisfranc). — The  flaps  X 
and  Y.  with  pedicles  lateral  as  outlined,  are  shifted  inward  and  sutured  in  the  midline,  AB 
to  CD. 

Fig.  565. — Operation  for  the  reconstruction  of  the  upper  lip  {Btirow). — The  dark  lines 
indicate  the  incisions  for  the  lateral  flaps.  The  shaded  triangular  areas  indicate  the  slack 
normal  tissue  removed.      The  flaps  are  shifted  inward  and  sutured  in  the  midline,  AB  to  CD. 


Fig.  566. — Operation  for  the  reconstruction  of  the  upper  lip  (Denonvilliers). —  i  and  2. 
The  flaps  are  outlined  and  shifted  downward  and  inward,  AB  being  sutured  to  CD  in  the 
midline. 

Bilateral    Flaps   with   Pedicle  Below. — Denonvilliers  (1854) 
constructed  an  upper  lip,  which  was  totally  lacking,  by  using  two 


5i6 


PLASTIC    SURGERY 


large  vertical  flaps  through  the  full  thickness  of  the  cheek  with  pedicle 
below.  The  internal  border  of  the  flaps  was  continuous  with  the  loss 
of  substance,  and  the  external  with  an  incision  just  in  front  of  the 
masseter  muscle,  and  extending  from  the  inferior  border  of  the  lower 
jaw  to  the  level  of  the  ala  of  the  nose.     A  transverse  cut  joined  the  two. 


Fig.  567. — Operation  for  the  reconstruction  of  the  upper  Hp  (modified  from  Nelaton 
and  Ombredanne). — i  and  2.  The  flaps  are  outlined  as  indicated  and  shifted  downward  and 
inward.  The  lines  AB  forming  the  border  of  the  lip  after  the  lines  BC  have  been  sutured 
in  the  midline. 

The  flaps  were  loosened  and  turned  toward  the  midline  where  the  upper 
borders  were  sutured.  The  inner  margin  of  the  flaps  form  the  free 
border  of  the  lip,  and  the  mucous  membrane  is  sutured  to  skin  to  form 
the  vermilion  line. 

Nelaton  and  Ombredanne  utilize  a  flap  from  each  cheek  with  the 
pedicle  below,  but  with  the  lateral  incision  not  extending  below  the 

level  of  the  commissures.  This  operation  is 
an  improvement  on  that  of  Denonvilliers  in- 
asmuch as  the  commissures  are  not  distorted, 
the  vermilion  line  is  reconstructed,  there  is 
little  tension  on  the  flaps,  the  lip  is  of  the 
W  proper  height  and  well  lined  with  mucosa. 
/  Bilateral  Flaps  with  Pedicles  Above. — 

Fig.   568.— Operation  for  In  Sedillot's  Operation  a  rectangular  vertical 

the  reconstruction  of  the  upper    n  •  •      j    r  t        *j  '^^     J.^  j*    i 

lip  (Sediiioi).— The  flaps  X  ^^P  ^^  raised  from  each  side  with  the  pedicle 
and  Y.  with  pedicles  above,  above.     Its  base  is  ou  a  level  with  the  com- 

are  raised  and  shifted  upward         .  .  .  .       . 

and  inward,  the  free  ends  AB  missurcs,  and  IS  coutmuous  with  it  ou  its  inner 
midiiSe^  ^"''^  "'"''"""^  ''"  *^'  border,  the  free  end  being  at  the  lower  margin 

of  the  mandible.     These  flaps  are  shifted  up- 
ward and  inward,  the  lower  borders  being  united  in  the  midline. 

Szymanowski  also  used  a  flap  with  the  pedicle  above.  The  axis 
of  the  flap  is  downward  and  outward,  and  all  the  incisions  are  curved. 
The  lower  incision  begins  at  the  commissure,  the  upper  at  the  level  of 
the  ala. 


SURGERY    OF    THE    LIPS 


517 


The  deformity  following  these  operations  is  much  more  marked  than 
when  the  pedicle  is  below;  moreover,  the  lower  lip  is  likely  to  be  much 
distorted. 

Reconstruction  of  the  upper  lip  has  been  attempted  by  using  flaps 
from  the  forehead,  but  unless  the  under  surface  of  the  flap  has  been 
previously  grafted,  or  has  been  folded  on  itself,  the  procedure  is  useless. 
This  also  holds  for  pedunculated  flaps  from  the  arm.  If  one  of  these 
methods  is  to  be  used  my  preference  would  be  for  the  arm  flap,  but  of 
course  each  case  must  be  dealt  with  on  its  own  merits.  The  Italian 
method,  unless  the  flap  has  been  previously  lined,  should  not  be  used 
to  reconstruct  the  upper  lip. 


123  4 

Fig.  569. — Method  of  forming  an  upper  lip  {Cole:  by  permission  of  the  Editor  of  the  ■ 
Practitioner). — i.  The  outline  of  the  hinged  flaps  with  pedicles  at  the  margin  of  the  defect 
are  indicated  by  the  dotted  lines.  2.  The  hinged  flap  turned  in  and  sutured  in  the  midline. 
3.  A  flap  from  the  scalp  turned  down  and  covering  one-half  of  the  lip.  A  flap  from  the 
other  side  of  the  scalp  is  used  to  cover  the  other  half.  4.  The  result  of  the  plastic  opera- 
tions.    All  defedts  should  be  closed  by  sutures,  or  grafted. 


SECONDARY  RECOXSTRUCTIOX  OF  THE  UPPER  LIP 

The  utilization  of  the  scar  tissue  w^hich  covers  the  surface  of  the 
defect  is  open  to  question,  on  account  of  poor  circulation.  Neverthe- 
less, we  are  often  tempted  to  use  it,  especially  for  lining  a  flap  of  skin 
brought  in  from  elsewhere  (the  arm  or  forehead).  I  have  had  some 
success  with  tissue  of  this  type,  but  a  flap  previously  lined,  or  a  flap  of 
normal  skin  turned  in  to  line  the  defect,  is  to  be  preferred,  and  in  the 
end  will  give  the  best  results. 

Berger  uses  a  single  flap  of  sufficient  width  and  length,  with  the 
pedicle  below,  to  reconstruct  the  upper  lip.  It  is  slightly  curved  and 
has  a  square  end  which  is  on  a  level  with  the  top  of  the  defect,  its  pedi- 
cle being  on  a  level  with  the  commissure,  and  its  inner  border  continuous 
with  the  defect.     It  includes  the  full  thickness  of  the  cheek  and  is 


PLASTIC    SURGERY 


shifted  downward  and  inward,  the  upper  border  being  sutured  to  the 
freshened  edge  of  the  lip  on  the  opposite  side.     The  margin  of  the  lip 


Fig.  570. — Operation  for  the  reconstruction  of  the  upper  lip  (Berger).- — i.  The  outline 
of  the  cheek  flap  which  is  shifted  downward  and  inward  to  fill  the  defect.  2.  The  flap  in 
position. 

is  formed  by  the  inner  edge  of  the  flap,  and  the  mucous  membrane 
lining  is  sutured  to  the  skin  to  form  the  vermilion  border  (Fig.  570). 
Gurdon  Buck's  Operation  for  the  Reconstruction  of  the  Upper  Lip 

by  Using  a  Flap  from  the  Lower  Lip. — 

He  divides  the  extremity  of  the  lower 
lip  where  it  joins  the  cheek  through  its 
entire  thickness  at  right  angles  to  its 
border  for  2.5  cm.  (i  inch).  From  the 
end  of  this  incision  he  m.akes  another  in- 
cision 3.75  cm.  (ij.^  inches)  parallel  to 
the  lip  border  and  extending  toward  the 
chin.  If  necessary,  he  partially  divides 
the  base  of  this  quadrilateral  flap  with 
an  oblique  incision  which  gives  more 
freedom  to  the  flap.  The  remaining  por- 
tion of  the  upper  lip  is  loosened  and 
shifted  toward  the  defect,  and  the  ver- 
milion edge  of  the  half  lip  is  separated 


Fig.  571. — Operation  for  recon- 
struction of  the  upper  lip  (Buck). — 
The  dark  lines  indicate  the  incisions 
outlining    the    flap    from    the    lower 

lip.  the  pedicle  of  which  is  at  the  sufhcientlv  to  meet  that  of  the  flap  from 

point   D.     This   flap   is   shifted   up-      ,        i  ^  ,. 

ward  to  fill  the  defect  in  the  upper    the    lower    lip 

lip,  and  is  sutured  to  the  freshened    „„.^     T-,o,,^     U^^^      f i,    „     ^ 

normal  edges.  g^P    ^^^'^    ^een    freshened 


After  the  edges  of  the 
have    been    freshened,    the   flap   is 
sutured  into  place.     Subsequently  it  be- 
comes necessary  to  lengthen  the  commissure  on  that  side  (Fig.  571). 
I  was  able  in  one  instance  to  reconstruct  the  upper  lip — in  a  case 
in  which  there  was  also  anchylosis  of  the  jaws  and  complete  obhteration 


SURGERY    OF    THE    LIPS 


519 


of  the  buccal  mucosa  on  that  side — by  employing  the  following  pro- 
cedure: the  cheek  was  separated  from  the  jaws  on  the  right  side  and 


I  2  3 

Fig.  572. — Restoration  of  the  upper  lip  and  lining  the  cheek,  for  a  defect  following 
•noma.  Duration  twelve  years. — i.  Xote  the  absence  of  the  right  side  of  the  upper  lip 
and  ala.  The  upper  teeth  have  been  turned  outward  by  scar  contracture.  The  jaws  are 
locked.  2  and  3.  The  result  of  turning  up  a  pedunculated  flap  from  the  neck  to  line  the 
•cheek.      Note  the  neck  scar  and  the  position  of  the  pedicle. 

was  lined  by  using  a  pedunculated  flap  turned  up  from  the  neck.     After 
the  lining  had  become  assured  the  vermilion  border  was  detached  from 


Fig.  573. — Restoration  of  the  upper  lip,  continued. —  i.  After  the  lining  of  the  cheek  was 
assured  the  pedicle  was  cut  and  fitted  into  position.  The  upper  lip  was  loosened  on  the 
left  side  and  shifted  toward  the  right.  The  lined  cheek  was  shifted  inward  and  the  flaps 
were  sutured,  thus  filling  the  defect.  The  vermilion  border  was  formed  with  flaps  from  the 
upper  and  lower  lips.  Photograph  taken  ten  days  after  the  operation.  2.  Shows  the 
result  of  the  repair  of  the  ala  by  means  of  a  flap  from  the  cheek  covering  a  flap  turned  down 
from  the  nose.  3.  Five  months  after  discharge  from  the  hospital.  Compare  with  the 
original  condition.  The  jaws  can  be  partially  opened  as  the  result  of  removal  of  the  condyle 
on  the  right  side.     Secondary  shaping  operations  will  be  necessary  to  complete  this  case. 

the  remaining  portion  of  the  lip  on  the  other  side,  and  then  by  means  of 
a  horizontal  incision  close  to  the  nose  the  lip  was  loosened  and  shifted 
toward  the  defect.     The  lined  portion  of  the  cheek  was  then  shifted 


520  PLASTIC    SURGERY 

inward  and  sutured  to  the  lip  flap  from  the  other  side,  and  the  vermilion 
border  was  completed  by  joining  that  on  the  upper  to  a  flap  obtained 
from  the  lower  lip.  The  angle  of  the  mouth  was  subsequently  length- 
ened and  the  result  was  satisfactory,  the  lip  being  lined  with  mucous 
membrane  and  with  a  portion  of  the  pedunculated  flap  which  had  been 
turned  up  from  the  neck  to  line  the  cheek.  Subsequently  the  condyle 
was  removed  on  that  side,  and  motion  of  the  jaw  was  improved  (Figs. 
572-573J- 

lAniEDIATE  RECONSTRUCTION  OF  THE  LOWER  LIP 

Frenx'H  Method. — This  method  ordinarily  entails  a  considerable 
amount  of  tension  on  the  line  of  sutures.  Then,  if  any  infection  occurs 
— which  is  not  an  infrequent  happening — we  may  have  a  fistula  in  the 
suture  line,  or  a  notch  at  the  margin.     In  other  cases  the  wound*  will 


I  2  3 

Fig.  574.  Fig.  575. 

Fig.  574. — Closure  of  V-shaped  defect. — i.  A  V-shaped  excision  of  a  growth  in  the 
midline  has  been  made.  2.  The  edges  have  been  closed  in  a  vertical  line.  If  the  gap  is 
wide  the  method  is  not  to  be  advised,  inasmuch  as  the  tension  may  cause  the  stitches  to 
tear  out. 

Fig.  575. — The  W-shaped  excision  of  Bouisson. — The  growth  has  been  excised  by  a 
W-shaped  incision.  The  points  A  and  C  are  joined  and  the  wedge  B  is  drawn  up  to 
complete  the  closure. 

break  down  completely.     Square  flaps  are  more  satisfactory  than  tri- 
angular flaps. 

Partial  Loss  of  SL■:BSTA^XE. — When  we  have  a  small  V-shaped 
defect,  the  edges  may  be  approximated  and  sutured.  If  the  gap  is 
wider,  Nelaton  and  Ombredanne's  operation  is  advisable.  A  V-shaped 
area  of  tissue  from  the  full  thickness  of  the  lip  containing  the  growth  is 
removed  with  a  wide  margin  of  normal  tissue.  This  wedge  of  tissue 
extends  down  to  the  point  of  the  jaw.  Then  one  or  two  incisions  (as 
may  be  necessary^  are  made  parallel  to  and  below  the  jaw  extending 
as  far  out  as  the  carotid  artery,  and  through  these  incisions  the  glands 
are  removed.  The  lip  and  neck  wounds  are  then  closed,  drainage  being 
provided  for.     Suture  of  the  Hp  defect  causes  great  constriction  of  the 


SURGERY    OF    THE    LIPS 


;2i 


mouth  which,  however,  can  be  remedied  by  making  an  angled  incision 
in  the  cheek  on  each  side,  and  lengthening  the  commissures.  Care 
must  be  taken  to  suture  skin  to  mucosa  everywhere  (Fig.  576). 

Complete  Loss  of  Substaxce. — All  flaps  from  the  chin  are  without 
a  lining  of  mucosa,  and  for  this  reason  will  subsequently  contract. 


K. 


Ot-V-  »  -^ 


Fig.  576. — Operation  for  repair  of  lower  lip  (modified  from  Xelalon  and  Ombredanne). — 
I.  Shows  extent  of  excision  of  lip.  The  dark  line  indicates  the  neck  incision  for  removal  of 
the  glands.  2.  Result  of  closure  of  lip  defect  showing  constriction  of  mouth.  3.  The  line 
AB  is  sutured  to  the  line  BC.      Along  the  line  ED  the  buccal  mucosa  is  sutured  to  the  skin. 

The  single  square  flap  as  used  by  Chopart  (1785)  which  is  drawn  up- 
ward vertically  is  undesirable  because  the  subsequent  cicatricial  con- 
tracture usually  draws  down  the  newly  formed  lip  and  there  is  a  median 
gutter  through  which  the  saliva  runs.  Some  improvement  on  this 
method  may  be  made  by  lining  the  lower  lip  with  a  pedunculated  flap 


B'  a: 


Fig.  577. — Chopart-Alquie's  operation  for  the  reconstruction  of  the  lower  lip  with  a 
square  flap,  pedicle  inferior. — i  and  2.  Two  vertical  incisions  prolonging  the  sides  of  the 
loss  of  substance  are  made  as  far  down  the  neck  as  necessary.  The  flap  is  loosened  and 
shifted  upward  into  the  defect.  This  forms  the  lip  without  a  lining.  Alquie  modified 
Chopart's  operation  by  lining  the  lip  with  pedunculated  flaps  of  mucous  membrane  ABC 
and  A'B'D  from  each  cheek. 

of  cheek  mucosa  from  each  side,  which  is  sutured  across  the  midline,  as 
suggested  by  Alquie  (1855).  But  this  will  not  always  counteract  the 
tendency  for  the  new  lip  to  retract.  A  relaxation  incision  across  the 
neck  below  the  chin  may  be  of  advantage  when  this  t}-pe  of  operation 
is  chosen  (Fig.  577). 

The  flap  from  below  may  have  a  split  pedicle,  one  portion  from 
each  side  of  the  midline,  as  in  Zeiss'  operation;  or  the  flaps  may  be 
double,  one  from  each  side,  as  used  by  Szymanowski. 


;22 


PLASTIC    SURGERY 


Bilateral  flaps  stretched  transversely  are  even  less  desirable  than 
the  square  flaps,  because  they  are  less  mobile.  They  may  be  useful 
for  the  small  losses  of  substance,  but  the  advisability  of  utilizing  this 
method  for  total  restoration  of  the  lower  lip  is  questionable.     In  the 


Fig.  578.  Fig.  579. 

Fig.  578. — Operation  for  the  reconstruction  of  the  lower  lip  with  double  vertical  flaps, 
pedicles  below  (Zeiss). — The  dark  lines  indicate  the  outlines  of  the  flaps  which  are  shifted 
upward.  The  V-shaped  area  X  below  the  flaps  is  used  as  a  buttress.  The  newly  formed 
lip  is  without  an  epithelial  lining. 

Fig.  579. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps,  pedicles 
external  iSerre). — The  lower  lip  has  been  removed  leaving  a  quadrangular  defect.  An  in- 
cision on  each  side  is  made  prolonging  the  commissures.  Another  incision  is  made  parallel 
to  the  above,  and  on  the  level  with  the  lower  border  of  the  defect.  The  flaps  thus  made 
through  the  full  thickness  of  the  cheeks  are  shifted  inward  and  sutured  in  the  midline  AB 
to  A'B'. 

operations  of  Lisfranc  ^1829).  Malgaigne  C1834),  or  Sedillot  (1856), 
horizontal  or  slightly  curved  incisions  are  made  from  the  angles  out- 
ward as  far  as  the  masseter,  and  the  flaps  thus  formed  are  drawn  inward 
and  sutured  in  the  midline.     To  this  group  may  be  added  the  operation 


n 


V 


Fig.  580.  Fig.  581. 

Fig.  580. — Operation  for  the  reconstruction  of  the  lower  lip  {Lisfranc). — The  dark 
lines  indicate  the  incisions.  The  points  A  and  B  are  approximated  and  the  edges  are 
sutured  vertically  in  the  midline. 

Fig.  581. — Operation  for  the  reconstruction  of  the  lower  lip  (Sedillot). — The  dark  lines 
indicate  the  incisions.  The  flaps  are  then  shifted  toward  the  midline  and  sutured  vertically, 
A  to  B.  (Note  the  utilization  of  small  flaps  from  the  vermilion  border  of  the  upper  lip  on 
each  side,  C  and  D,  to  form  a  margin  for  the  lower  lip.) 

of  Pollosson,  who  uses  an  angled  incision.     Sedillot  utilizes  a  flap  of  the 
vermilion  border  taken  from  the  upper  lip  on  each  side. 

In  this  group  Diefifenbach  and  Desgranges  (^1853)  utilize  the  ver- 
milion border  of  the  upper  lip  to  surround  the  mouth,  secondary  opera- 
tions being  necessary  to  lengthen  the  commissures.     The  operation  of 


SURGERY    OF    THE    LIPS 


523 


C.  Bernard  leaves  the  upper  lip  much  puckered,  and  excision  of  triangles 
of  healthy  skin  at  the  angles,  after  the  method  of  Burow,  is  used  to 
correct  this  defect. 

The  operation  of  Xelaton  and  Ombredanne,  which  was  previously 
described  when  we  spoke  of  partial  loss  of  substance,  is  a  much  better 


Fig.  582. — Operation  for  the  reconstruction  of  the  lower  lip  (Beau). — i  and  2.  The 
dark  lines  indicate  the  incisions.  The  flaps  A  and  B  are  shifted  upward  and  sutured  in  the 
midline.      They  are  buttressed  on  the  point  X. 


Fig.  583. — Operation  for  the  reconstruction  of  the  lower  lip  {Weber). — i  and  2.  The 
dark  lines  indicate  the  incisions  outlining  the  flaps  X  and  Y,  which  are  raised  and  super- 
imposed. The  point  B  is  sutured  to  the  commissure  at  D.  and  the  point  E  to  the  base 
of  the  flap  X  at  C.      The  newly  formed  lip  is  without  epithelial  lining. 


/V    ^  '    V\ 


Fig.  584. — Combined  operation  for  the  reconstruction  of  the  lower  lip  {Serre). — i.  The 
dark  lines  indicate  the  incisions.  The  flap  X  is  shifted  upward.  The  vermilion  line  BC 
is  shifted  in  the  direction  of  the  arrow  and  sutured  to  AN.  The  cheek  flap  MKH  is  under- 
cut and  shifted  upward,  K  being  sutured  to  A.  The  flap  X  is  then  shifted  upward,  the 
edge  EL  being  sutured  to  DA'.  2.  The  dark  lines  indicate  the  incisions.  The  flap  Y  is 
shifted  upward.  NK  being  sutured  to  FH.  The  flap  X  is  shifted  outward,  the  line  AB  being 
sutured  at  the  line  EO. 


procedure  for  widening  the  mouth,  and  by  its  use  the  sacrifice  of  the 
triangles  of  skin  is  avoided. 

Flaps  stretched  obliquely  are  also  less  mobile  than  square  flaps, 
and  are  even  less  desirable  than  the  flap  with  its  pedicle  transverse. 


524 


PLASTIC    SURGERY 


as  the  lower  border  of  the  new  Hp  soon  retracts.  These  flaps  may  be 
unilateral  (Roux,  1828,  and  Szymanowski)  with  pedicle  below  and 
oblique,  or  bilateral  (Beau,  1869,  and  Weber)  with  pedicles  below  and 
oblique.  In  these  flaps  there  is,  of  course,  no  mucous  lining,  so  that 
they  soon  contract. 


Fig.  585. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps,  pedicles 
below  (Dieffenbach). — i  and  2.  The  outlines  of  the  flaps  through  the  full  thickness  of  the 
cheek  are  indicated  by  the  dark  lines.  They  are  shifted  inward  and  sutured  A  to  B  in 
the  midline.      The  defects  left  in  the  cheeks  are  filled  by  shifting  in  neighboring  soft  parts. 


,L^nx 


I  2 

Fig.  586. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps,  pedicles 
below  (Adelmann). — i  and  2.  The  dark  lines  indicate  the  incisions  which  penetrate  to  the 
mucosa.  The  flaps  are  shifted  inward  and  are  sutured  in  the  midline.  The  cheek  defects 
are  narrowed  by  drawing  in  the  surrounding  soft  parts.  The  lip  thus  formed  is  not  lined 
with  epithelium. 


Fig.  587. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps,  pedicles 
below  (Jdsche). — i  and  2.  The  curved  dark  lines  indicate  the  incisions  through  the  full 
thickness  of  the  cheeks.      These  are  shifted  inward  and  sutured  in  the  midline,  A   to  B. 

Erichsen  excises  triangles  of  normal  tissue  at  the  angles,  and  in  the 
midline  below,  but  when  the  wounds  are  closed  there  is  constriction 
of  the  buccal  orifice  together  with  a  considerable  amount  of  scarring. 

All  of  the  operations  by  the  French  method  in  which  bilateral  flaps 


SURGERY    OF    THE    LIPS 


525 


are  used  are  designed  to  reconstruct  symmetrical  lesions  of  the  lip, 
exactly  similar  procedures  being  carried  out  on  each  side.  When  the 
lesion  is  not  symmetrical  some  combined  method,  such  as  that  suggested 
by  Serre  in  which  a  lateral  flap  and  a  flap  from  below  are  shifted,  may 
be  advantageous,  although  the  result  may  not  be  a  cosmetic  success. 

IxDiAX  Method.     Flaps  from  the  Cheek  and  Chin. — The  ped- 
icles may  be  below,  as  typitied  by  DiefTenbach's  operation  in  which  a 


Fig.  588. — Operation  for  reconstruction  of  the  lower  lip  (Heurtaux). — i.  The  dark  line 
indicates  the  incision.  The  dotted  lines  show  the  area  of  redundant  tissue  which  should 
be  excised  when  the  flap  is  in  position.      2.   Shows  the  flap  sutured  into  the  defect. 

flap  through  the  full  thickness  of  the  cheek  is  shifted  in  from  each  side 
and  sutured  in  the  midline.  Adelmann's  operation  is  much  like  that 
of  Diefl'enbach's  except  that  the  flaps  are  much  more  extensive,  the 
external  border  being  on  the  masseter  muscle,  and  the  incisions  do  not 
go  through  the  mucosa.  Xelaton  and  Ombredanne  have  also  modified 
Dieffenbach's  operation.     In  Jasche's  operation  the  incisions  are  curved 


Fig.  589. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps,  pedicles 
below  (Reid). — i  and  2.  The  dark  lines  indicate  the  outlines  of  the  flaps  through  the  full 
thickness  of  the  cheeks.     They  are  shifted  inward  and  sutured  in  the  midline,  A  to  B. 

and  pass  from  the  commissures  outward  and  slightly  upward,  and  then 
downward,  parallel  to  the  borders  of  the  defect,  as  far  as  necessary  on 
the  neck.  The  full  thickness  of  the  cheek  is  included.  Heurtaux 
(1893)  makes  a  similar  curved  incision,  but  uses  only  one  flap.  In 
order  to  prevent  puckering  of  the  skin  on  the  convex  side  of  the  curve 
he  excises  a  triangular-shaped  piece  of  skin.     The  excision  of  the  skin 


526 


PLASTIC    SURGERY 


may  be  obviated  by  making  the  original  incision  curve  backward  so 
that  the  entire  cut  has  an  S-shape. 

In  Ried's  operation  the  incisions  are  curved  much  the  same  as  in 
Jasche's,  but  when  the  lower  jaw  is  reached  they  are  brought  back  paral- 
lel to  it  toward  the  chin. 


Fig.  590. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps  (Polloson) . — 
I  and  2.  The  dark  lines  indicate  the  incisions  through  the  cheeks.  The  lateral  flaps  are 
shifted  inward  and  are  sutured  in  the  midline,  A  to  B.  The  mucosa  is  broughtjforward 
and  sutured  to  the  skin  to  form  the  vermilion  border. 


Fig.  591 . — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps  (Berger) . — 
I  and  2.  Incisions  continuous  with  the  commissures  are  made  on  each  ^side  and  the 
mucous  membrane  and  skin  are  sutured  together. 


Fig.  592. — Operation  for  the  reconstruction  of  the  lower  lip  with  lateral  flaps,  con- 
tinued.— I  and  2.  Several  weeks  later  flaps  are  made  as  indicated  by  the  dark  lines,  and 
shifted  toward  the  midline,  where  they  are  sutured,  AC  to  BC. 


Berger  performs  Dieffenbach's  operation  in  two  stages.  This  is 
much  safer,  although  it  takes  longer  to  secure  a  result.  He  makes  a 
horizontal  incision  from  each  corner  of  the  mouth  extending  the  desired 
distance.  This  penetrates  all  the  tissues  down  to  the  mucosa,  which 
is  divided  i.  cm.  (2g  inch)  above  the  skin  incision.  The  flap  of  mucosa 
is  turned  out  and  sutured  to  the  skin  on  the  lower  side,  and  will  even- 


SURGERY    OF    THE    LIPS 


527 


tually  form  the  vermilion  border  of  the  new  lip.  The  skin  and  mucosa 
are  sutured  together  in  all  places  where  this  is  possible.  This  procedure 
makes  an  opening  twice  the  length  of  the  normal  mouth.  After  several 
weeks  the  scar  tissue  is  removed  from  the  edges  of  the  lip  defect  and 
along  the  upper  border  of  the  cheek  incision.  Lateral  incisions  are 
made  on  each  side  from  the  corners  of  the  mouth  downward,  and  parallel 
to  the  borders  of  the  lip  defect,  and  the  flaps  thus  made,  including  the 
full  thickness  of  the  cheek,  are  shifted  toward  the  midline.  Sutures 
are  inserted  and  the  lip  and  mouth  reconstructed.  The  lateral  open- 
ings left  by  shifting  the  flaps  are  filled  by  undercutting  and  shifting  in 
the  soft  parts.  A  similar  procedure  may  be  used  on  one  side  only  if  the 
defect  is  unilateral. 

Nelaton  and  Ombredanne's  Operation  for  Extensive  Loss  of  Sub- 
stance of  the  Lower  Lip. — The  defect  is  first  made  triangular  in  shape. 
A  vertical  incision  is  made  on  the  neck  from  the  apex  of  the  triangle. 


Fig.  593. — Operation  for  the  reconstruction  of  the  lower  lip  in  extensive  defects 
(modified  from  Nelaton  and  Ombredanne). — i  and  2.  The  dark  line  indicates  the  incision 
made  on  each  side  of  the  defect  to  form  the  flap  X. 


From  the  angles  of  the  mouth  incisions  are  made  through  the  skin  only, 
to  just  below  the  tragus,  and  then  from  this  point  parallel  to  the  border 
of  the  defect  downward  below  the  lower  edge  of  the  mandible.  The 
mucous  membrane  is  then  divided  on  the  cheek  0.8  cm.  (about  3^3 
inch)  above  the  skin  incision,  and  in  reflecting  the  flap  downward  the 
operator  also  divides  it  along  the  anterior  border  of  the  masseter. 
Mucous  membrane  is  sutured  to  skin  to  form  a  new  vermilion  border. 
The  flaps  are  reflected,  care  being  taken  not  to  disturb  the  parotid 
gland  or  the  facial  artery.     After  excision  of  the  glands  the  lower 


528 


PLASTIC    SURGERY 


mucous  border  is  sutured  to  the  mucosa  of  the  lower  jaw,  and  the  flaps 
are  raised  and  the  necessary  sutures  are  inserted,  thus  closing  the  lip 
defect.  This  is  certainly  an  effective  procedure  but  is  quite  radical, 
and  should  be  undertaken  only  in  exceptional  cases  (Figs.  593-594). 


Fig.  594. — Operation  for  the  reconstruction  of  the  lower  lip  in  extensive  defects,  con- 
tinued.— I.  The  flap  X  turned  back.  Y  indicates  the  lining  of  the  lower  lip  formed  from 
the  mucous  membrane  of  the  cheek.      2.   The  flaps  sutured  in  position,  and  the  lip  formed. 

Flaps  with  Lateral  Pedicles. — These  flaps  are  easy  to  obtain  and 
apparently  fill  the  defect  nicely,  but  unless  they  are  lined  little  can  be 
accomplished.  It  is  best  to  employ  a  lining  flap  first,  obtained  from 
the  situation  most  favorable,  and  then  cover  the  raw  surface  with 
the  lateral  flap. 


Fig.  595. — Operation  for  the  reconstruction  of  the  lower  lip  (Anger). — i  and  2.  The 
dark  lines  indicate  the  incisions  made  to  form  the  flap  which  is  raised  from  the  chin  and 
neck.      It  is  shifted  upward  to  fill  the  defect.      The  lip  is  not  lined  with  epithelium. 

The  defect  from  which  the  flap  is  raised  can  usually  be  closed  by 
undercutting  and  shifting  neighboring  skin;  when  this  is  not  possible 
the  raw  surface  should  be  grafted.  The  use  of  lateral  flaps  without 
lining  cannot  be  recommended,  but  as  this  type  of  flap  may  be  used  in 
combination  with  others,  I  shall  mention  some  of  the  methods. 

The  flaps  are  raised  from  the  skin  of  the  chin  or  neck,  and  may  be 


SURGERY    OF    THE    LIPS 


529 


unilateral  or  bilateral.  Anger  (1877)  utilizes  a  unilateral  quadrangular 
flap  from  the  skin  of  the  neck  and  chin  to  repair  a  total  absence  of  the 
lower  lip.  For  a  less  extensive  defect  Ledran  shifts  up  a  flap  from  the 
chin.     Berg  does  a  very  similar  operation. 


Fig.   596. — Operation  for  the  reconstruction  of  the  lower  Up  (Ledran). — i  and  2.   The  flap 
X  is  outlined  by  dark  lines.     It  is  shifted  upward,  the  line  AB  being  sutured  to  CD. 


Fig.  597.^0peration  for  the  reconstruction  of  the  lower  lip  (Berg). — i  and  2.  The 
flap  is  indicated  by  dark  lines.  This  flap  is  raised  and  shifted  to  cover  the  defect,  the  point 
B  forming  the  commissure  at  D. 


Fig.  598.  Fig.  599. 

Fig.  598. — Operations  for  the  reconstruction  of  the  lower  lip  (Dieti-Lafoy). — The  flaps 
are  outlined  by  the  dark  lines.  They  are  shifted  upward  and  sutured  in  the  midline,  the 
points  A  and  B  meeting  at  the  lip  margin. 

Fig.  599. — Operation  for  the  reconstruction  of  the  lower  lip  (Auvert). — The  dark  lines 
indicate  the  incisions.  The  flaps  are  shifted  upward  and  sutured  in  the  midline,  the  points 
F  and  C  meeting  in  the  midline  of  the  margin  of  the  lip. 


Bilateral  Flaps. — Dieu-Lafoy  uses  a  double  flap  for  repairing 
a  wide  but  comparatively  shallow  loss  of  substance.  He  makes  a 
midline  vertical  incision  to  the  inferior  border  of  the  mandible,  and  then 
two  lateral  incisions  of  the  desired  length  along  the  inferior  border 
of  the  lower  jaw.  Auvert,  for  more  extensive  defects,  uses  much  larger 
flaps.  He  makes  a  median  incision  down  to  the  thyroid  cartilage,  and 
34 


53° 


PLASTIC    SURGERY 


lateral  incisions  in  the  skin  of  the  neck.     The  flaps  are  loosened  and 
shifted  upward. 

Flaps  with  a  Double  Pedicle. — This  method  has  been  used  by 
Viguerie-Morgan,  Wolfler,  Mazzoni,  and  others.  A  bridge  flap  is  made 
by  means  of  a  horseshoe  or  widely  spread  V-shaped  incision,  parallel 
to  the  border  of  the  inferior  maxilla,  and  extending  as  far  on  each  side 
,  ,    as  may  be  necessary.     The  commissures  are 

lengthened  by  horizontal  incisions  parallel  to 
the  above.  The  flap  thus  marked  out  is 
separated  from  the  underlying  tissues  and 
shifted  upward  to  cover  the  defect.  Re- 
dundant tissue  will  be  found  at  the  com- 
missures and  should  be  removed  in  the  way 
best  suited  to  the  case.  Sandelin  uses  the 
bridge  flap,  and  in  addition  to  sutures  holds 
it  in  position  by  means  of  a  tack  (I  have 
found  this  useful  and  have  employed  a  wire 
staple)  driven  through  the  f.ap  into  the  mental  process  of  the  mandible. 
He  then  covers  the  upper  border  with  a  double-pedicled  flap  of  mucosa 
from  the  upper  lip,  after  the  method  of  Schulten,  which  will  be  de- 
scribed later. 

Flaps  with  Pedicles  Above. — When  extensive  defects  of  the  lower 
lip  are  closed  by  flaps  with  pedicles  above,  these  must  be  bilateral. 


Fig.  600. — Operation  for 
the  reconstruction  of  the  lower 
lip  ( Vigiierie-M organ) . — The 
double  pedicled  flap  is  outlined 
by  the  dark  lines.  It  is  shifted 
upward  forming  the  lower  lip. 


Pig.  601. — Operation  for  the  reconstruction  of  the  lower  lip  (Sedillot). — i  and  2.  The 
lateral  flaps  with  pedicles  above  are  indicated  by  the  dark  lines.  They  are  raised  and 
turned  upward  and  inward,  the  extremities  AB  and  A'B'  being  sutured  together  in  the 
midline.      The  square  area  C  on  the  chin  supports  the  flaps. 

This  method  has  been  used  by  several  surgeons,  and  the  operation  of 
Sedillot  (1848)  may  be  taken  as  a  type.  He  raises  from  each  side  a 
flap  of  sufficient  width  and  extending  from  the  level  of  the  commissures 
vertically  downward  as  far  as  necessary  on  the  neck.  The  flaps  are 
turned  upward  and  inward,  and  are  sutured  in  the  midline  and  across 
the  base.  Sedillot  did  not  at  first  utilize  the  mucous  membrane  lining 
the  upper  portion  of  the  flap,  but  Bouisson  attempted  to  line  the  lip 


SURGERY    OF    THE    LIPS 


531 


with  it,  and  later  Sedillot  used  a  portion  of  the  vermilion  border  of  the 
upper  lip  from  each  end  to  cover  the  commissures  and  a  part  of  the 
margin  of  the  new  lip. 

Xelaton  and  Ombredanne  employ  a  curved  flap  from  each  side, 
utilizing  the  buccal  mucosa  on  the  flap,  and  also  a  portion  of  the  ver- 
milion line  of  the  upper  lip  to  complete  the  border  of  the  new  lip.     This 

\ 


"^^ 


K  Fig.  602. — Operation  for  the  reconstruction  of  the  lower  lip  {Lallemand) . — The  dark 
lines  indicate  the  incisions  outlining  the  flap  X.  It  is  raised  and  shifted  upward  into  the 
defect,  the  point  F  meeting  the  point  D. 

method  is  not  a  desirable  one  because  the  mucous  lining  of  the  lip 
is  lacking  over  a  considerable  portion,  the  commissures  are  distorted, 
and  secondary  operations  become  necessary.  In  addition,  the  upper 
border  of  the  lip  will  often  become  everted. 

Buttressed  Flaps. — Jumping  a  flap  from  the  chin  or  neck  over 
intervening  skin  and  underlying  tissues  on  the  chin,  w^hose  attachments 


Fig.  603. — Operation  for  the  reconstruction  of  the  lower  lip  (Langenbeck) . — i  and  2.   The 
flap  I  is  superimposed  and  buttressed  on  the  area  2,  which  is  not  detached  fjrom  the  chin. 

are  undisturbed,  is  an  old  method  and,  as  far  as  support  is  concerned, 
presents  a  good  deal  of  advantage  over  other  procedures  in  which  lateral 
attachments  and  sutures  are  mainly  depended  upon  for  support. 
The  flaps  may  be  unilateral  or  bilateral.  Lallemand  (1824)  obtained  a 
single  flap  of  suitable  size  and  shape  from  the  neck  below  the  defect, 
jumped  it  over  the  undisturbed  tissues  on  the  chin,  and  sutured  it  into 
the  defect. 

Langenbeck  employs  a  single  flap  from  the  chin  just  below  the  defect. 


532 


PLASTIC    SURGERY 


Landreau  uses  a  half-curved  single  flap  of  sufficient  length  and  width 
from  the  chin  and  cheek  with  its  pedicle  lateral,  and  level  with  the  com- 
missure on  one  side.     The  flexibility  of  the  tissues  allows  the  flap  to 


Fig. 


604. — Operation  for  the  reconstruction  of  the  lower  lip  {Landreau). — i  and  2.   The 
curved  flap  X  is  raised  and  shifted  into  the  defect,  A'B'  being  sutured  to  AB. 


be  straightened  and  sutured  into  position,  resting  on  the  undisturbed 
tissues  of  the  chin  (Figs.  603-604). 

Trelat's   operation  (1861)  may  be  taken  as  a  type  of  the  use  of 
bilateral  flaps.     A  quadrilateral  flap  is  raised  from  each  side  of  the 


Fig.  605. — Operation  for  the  reconstruction  of  the  lower  lip  (Trelat). — i  and  2.  The 
flaps  X  and  Y  are  raised  and  sutured  in  the  midline,  CD  to  CD'.  They  are  buttressed 
on  the  area  M. 

chin  leaving  a  square  broad  area  undisturbed  on  the  point  of  the  chin. 
Triangles  of  excess  tissue  down  to  the  mucosa  are  removed  from  the 
corners  of  the  mouth.     The  flaps  are  loosened  and  shifted  upward  and 


Fig.  606. — Buchanan-Syme's  operation  for  the  reconstruction  of  the  lower  lip. —  i  and 
2.  The  dark  lines  indicate  the  incisions.  The  flaps  are  shifted  upward  and  sutured  in  the 
midline,  HM  to  LN.     They  are  buttressed  on  C. 

sutured  in  the  midline  and  to  the  undisturbed  area  on  the  chin.  This 
will  leave  two  uncovered  surfaces  on  each  side  of  the  chin  which  may 
■be  sutured  or  else  grafted.     This  seems  to  me  a  better  operation  than 


SURGERY    OF    THE    LIPS 


533 


that  of  Blasius'  or  Buchanan-Syme's,  because  the  buttress  on  the  chin, 
being  square  instead  of  pointed,  gives  better  support.  Blasius  used 
curved  incisions  and  in  Buchanan-Syme's 
operation  the  incisions  are  angular.  Dowd's 
operation  is  very  similar  to  that  of  Buchanan- 
Syme,  but  an  additional  incision  is  made 
through  the  cheek,  extending  from  the  com- 
missures outward  in  order  to  mobilize  the 
flaps  more  completely  (Figs.  605-607). 

DouBLE-PEDiCLED  Flaps. — Oilier  uses  a 
curved  bridge  flap  with  pedicles  on  each 
cheek,  according  to  the  method  of  Viguerie- 
Morgan,  but  instead  of  shifting  up  all  the 
chin  tissue  a  central  buttress  is  left,  and  the  restores  the°w?^S%°oVdT 
bridge  flap  is  jumped  over  it  and  sutured    ~The  dark  lines  indicate  the 

.  .  incisions  made  in  the   removal 

into  position.  This  is  an  improvement  on  of  the  growth  (entire  lower 
\-iguerie-Morgan's  operation.  Morestin  J^J^  "^"^  jor^the  f«™ati„^„^of 
and  J.  F.  Baldwin  use  a  similar  method,  but    are  through  the  full  thickness 

, .         '  1        ^^  •   1  n  r  ,  •  1      r  of  the  cheek   and  when  united 

line  the  lip  with  a  flap  ot  scar  tissue  before  the  point  a  is  sutured  to  A',  and 
shifting  the  double-pedicled  flap  upward.  ^  ^°  ?'•  .'^^®  ™"':°Y\"'T" 

^  /  ^       ^  brane  is  divided  slightly  higher 

Grant's  Operation. — A  quadrangular  ex-   than  the  skin  in  making  the 
cision  is  made.     Then  from  the  inferior  angle 
of  the  wound  on  each  side  an    incision   is 
carried  obliquely  downward  and  backward 
across  the  mandible,  on  a  line  about  ec^uidistant  between  the  angle 
and    the    symphysis.     Through  these  incisions,  which  are  lengthened 


flap,  thus  providing  a  vermilion 
border  when  it  is  sutured  to  the 
skin.  CC  indicate  wedges  of 
slack  tissue  to  be  removed. 


I  2  34 

Fig.  608. — Cheiloplasty  (Morestin). —  i.  The  dark  lines  indicate  the  incisions.  The 
flap  of  scar  X  with  pedicle  above,  which  is  turned  up  to  line  the  lip.  The  buttress  flap,  Y. 
The  double  pedicled  flap  Z  which  is  raised.  2.  Shows  the  flap  Z  raised  and  placed  above 
the  buttress  Y.  3.  Diagrammatic  midline  section.  The  flap  AB  corresponds  to  the  flap 
Z.      The  flap  C  corresponds  to  the  flap  X.     4.   The  flaps  in  position. 

as  needed,  the  submaxillary  glands  are  removed,  a  separate  incision 
being  required  for  the  submental  gland.     The  edges  of  the  cheek  flaps 


534 


PLASTIC    SURGERY 


are  then  sutured  in  the  midline,  and  are  fixed  and  supported  by  the 
buttress  on  the  chin.  Tension  sutures  may  be  necessary,  and  the  angles 
of  the  mouth  may  have  to  be  lengthened  (Fig.  609). 

Flaps  from  the  upper  lip  may  be  unilateral  or  bilateral,  accord- 
ing to  the  width  of  the  defect.  They  have  the  advantage  of  being 
lined  with  mucosa  and  the  utilization  of  a  portion  of  the  red  border  of 


12  34 

Fig.  609. — Operation  for  restoring  the  lower  lip  (Grant). — i  and  2.  The  dark  lines 
indicate  incisions  made  in  removal  of  growth  on  the  lip,  and  for  the  plastic  repair.  3. 
Shows  retraction  of  the  tissues  after  the  incisions  are  made.  The  tissues  on  the  chin  are 
not  disturbed.  4.  Shows  the  wound  closed.  This  operation  is  a  good  one  and  has  the 
advantage  of  a  buttress  on  the  chin. 

the  upper  lip  near  the  angles  insures  a  satisfactory  commissure.     These 
flaps  seldom  evert,  and  good  results  are  usually  obtained. 

Larger's  Operation  (1894). — An  incision  is  made  through  the  full 
thickness  of  the  upper  lip  at  the  junction  of  the  outer  and  middle 
thirds.  This  is  extended  upward  and  outward  toward  the  ala,  to  the 
naso-labial  fold.     Joining  this  a  second  incision  is  made  parallel  to  this 


Kj  \  r  )j\ 


Fig.  610. — Operation  for  the  reconstruction  of  the  upper  Hp  (Larger). — i  and  2.  The 
flap  outlined  by  the  dark  lines  on  the  upper  lip  is  shifted  downward  and,  after  removal  of 
the  portion  of  the  vermilion  border,  is  sutured  into  the  defect  AB  to  CD. 

fold  and  extending  downward  to  a  point  below  the  level  of  the  commis- 
sure. The  portion  of  the  vermilion  border  which  is  attached  to  the 
lower  border  of  this  flap  is  removed.  The  flap  is  shifted  downward  and 
sutured  into  position,  and  skin  and  mucous  membrane  are  united 
wherever  possible.  The  cheek  wound  is  then  closed.  In  this  operation 
the  outer  third  of  the  vermilion  line  of  the  upper  lip  is  destroyed. 
Guinard  utilizes  this  mucous  membrane  in  the  formation  of  the  gingivo- 


SURGERY    OF    THE    LIPS 


535 


labial  groove,  which  is  an  improvement,  and  jNIorestin  has  employed 
this  portion  of  the  vermilion  line  (leaving  it  attached  to  the  upper  lip) 
in  forming  the  commissure  and  outer  portion  of  the  border  of  the  newly 
formed  lower  lip.  I  have  obtained  excellent  results  with  this  method 
(Fig.  6io). 

Estlander  used  a  single  flap  running  upward  and  outward  across 
the  naso-labial  fold,  with  its  base  at  the  junction  of  the  outer  and  middle 


Fig.  6ii. — Operation  for  the  reconstruction  of  the  lower  lip  (Estlander). —  i  and  2.  The 
flap  X.  from  the  upper  lip  and  chin,  is  turned  and  shifted  downward  into  the  defect.  The 
free  end  A  is  sutured  into  the  defect  at  B. 

third  of  the  upper  lip.  The  scarring  is  more  noticeable,  the  flap  has  to 
be  twisted  i8o°  on  its  pedicle,  which  is  quite  narrow  and  the  blood 
supply  is  doubtful.  In  my  opinion  this  procedure  is  not  to  be  com- 
pared with  the  modifications  of  Larger's  operation  (Fig.  6ii). 

The  bilateral  flap  of  von  Bruns  gives  almost  a  double  Larger's 
operation.     The  flaps  do  not  encroach  so  much  upon  the  upper  lip,  the 


Fig.  6x2. — Operation  for  the  reconstruction  of  the  lower  lip  (Bruns). —  i  and  2.  The 
flaps  from  the  upper  lip  are  outlined  by  the  dark  lines.  They  are  shifted  downward  to  fill 
the  defect.  AB  being  sutured  to  CD  in  the  midline. 

inner  border  being  in  the  naso-labial  fold.  As  the  best  operation  I 
would  suggest  a  modification  between  the  two  methods  to  suit  the 
individual  case  (Fig.  612). 

Flaps  from  the  skin  of  the  neck  as  originally  employed  are  not 
to  be  advocated.  Delpech  (1823)  and  many  others,  used  an  oval  flap 
with  its  pedicle  just  below  the  chin  and  extending  to  the  sternal  notch. 
Its  width  should  be  suflicient  to  fill  the  defect,  and  it  should  be  long 


536 


PLASTIC    SURGERY 


enough  for  its  free  end  to  be  reflected  on  itself  to  line  the  lip.  Then 
the  flap  is  twisted  i8o°  and  sutured  into  the  defect.  Voisin  (1835) 
used  a  triangular  flap  with  its  base  above,  and  did  not  attempt  to 
line  it  (Figs.  613-614). 

Flaps  have  also  been  raised  with  a  lateral  pedicle,  but  without 
much  success,  as  retraction  usually  takes  place.     My  experience  with 


Fig.  613. — Operation  for  the  reconstruction  of  the  lower  lip  (Delpech). — i  and  2.  The 
flap  as  outlined  is  raised  from  the  neck  and  is  folded  on  itself  at  the  line  AB.  The  pedicle 
is  then  twisted,  the  points  A  and  D  and  B  and  C  being  brought  together. 

neck  flaps  has  not  been  entirely  unfavorable,  in  fact  at  times  neck 
flaps  may  be  used  to  great  advantage.  A  neck  flap  with  its  base  above 
may  be  turned  up  without  twisting  to  line  the  lip  when  mucosa  cannot 
be  obtained,  and  its  surface  be  covered  with  a  flap,  or  flaps,  from 


Fig.  614. — Operation  for  the  reconstruction  of  the  lower  lip  (Voisin). — i  and  2.  The 
flap  as  outlined  is  raised  from  the  neck  and,  after  twisting  the  pedicle,  is  sutured  into  the 
defect,  the  points  A  and  D,  and  B  and  C,  being  brought  together.     This  flap  is  not  lined. 

elsewhere.  In  due  time  the  pedicle  is  cut,  the  chin  is  shaped,  and  any 
fistulous  tracts  are  attended  to.  The  free  end  may  be  reflected  on  it- 
self and  allowed  to  heal  before  shifting.  The  under  surface  of  the  flap 
may  be  grafted  either  by  the  open  or  by  the  buried  method,  and  then 


SURGERY    OF    THE    LIPS 


537 


after  being  twisted  may  be  sutured  into  the  defect.  These  procedures, 
of  course,  require  preliminary  preparation  if  they  are  used  imme- 
diately to  fill  an  operative  defect. 

Mauclaire  constructed  a  lower 
lip  and  also  replaced  the  skin  below 
(which  had  been  removed  at  opera- 
tion), by  using  a  tlap  whose  pedicle 
was  below  on  the  neck  at  the  side  of 
the  defect.  The  body  of  the  flap  ex- 
tended up  over  the  sterno-mastoid 
muscle,  and  its  free  end  was  on  the 
mastoid  process,  so  that  the  portion 
which  was  to  form  the  lower  lip  was 
covered  with  hair.  This  operation 
is  defective,  inasmuch  as  there  is  no 
lining  provided  for  the  lip,  and  when 
it  is  used  the  under  surface  of  the  free 
end  of  the  flap  should  be  grafted 
previously,  in  order  to  furnish  a  lining. 

Italian  ^Iethod.— There  is  little 
to  be  gained  from  the  use  of  a  flap 
from  the  arm  in  the  immediate  re- 
storation of  a  lower  lip  unless  this  flap 
has  been  previously  prepared  by  fold- 
ing the  end  on  itself,  or  grafting  the 
under  surface  to  form  a  lining.  If 
either  of  these  procedures  are  carried 
out,  the  double  epithelial-lined  flap  may  be  successfully  implanted  and 
later  shaped  as  desired.     The  arm  flap  may  be  also  used  to  cover  the 


— Operation  for  the  restora- 
tion of  the  lower  lip  and  skin  below)!  it. 
(Mauclaire). — The  dotted  area  indicates 
the  defect.  The  dotted  line  indicates  the 
outline  of  the  flap  A,  from  the  mastoid 
region  with  pedicle  below,  which  is  shifted 
forward  to  form  the  lip. 


Fig.  6i6. — Operation  for  the  reconstruction  of  the  lower  lip  (Polaillon) . — i.  The  flap 
X  is  turned  up  to  line  the  lip,  A  being  sutured  to  C,  and  B  to  D.  2.  Lateral  flaps  are 
shifted  in  from  the  cheeks  and  sutured  in  the  midline  to  form  the  external  surface  of  the  lip. 

raw  surface  of  a  flap  which  has  been  turned  up  from  the  neck  to  line 
the  lip.     Watts  reports  a  very  satisfactory  result  in  constructing  a 


538 


PLASTIC    SURGERY 


lower  lip  with  a  flap  from  the  arm.  the  raw  surface  of  which  had  been 
grafted  and  healed  before  the  transfer  of  the  flap. 

I  can  see  no  reason  why  this,  or  the  folding  method,  should  not  be 
used  more  frequently.     The  scarring  is  less  and  the  results  are  good. 


Fig.  617. — Operation  for  the  reconstruction  of  the  lower  lip  (Berger). — i.  The  dotted 
line  indicates  the  incision  made  to  turn  back  a  flap  of  scar  to  line  the  lip.  2.  The  flap  turned 
up. 


SECONDARY  RESTORATION  OF  THE  LOWER  LIP 

The  restoration  of  the  lip  in  old  losses  of  substance,  in  which  healing 
has  taken  place,  brings  in  the  problem  of  dealing  with  tissues  which  are 
more  or  less  infiltrated  with  scar.     Polaillon  excised  the  scar  and  used 


Fig.  618. — Operation  for  the  reconstruction  of  the  lower  lip,  continued  (Berger,  after 
Nelaton  and  Ombredanne) . — A  pedunculated  flap  from  the  arm  covering  the  raw  surface. 
Note  the  apparatus  holding  the  arm  in  position. 

a  flap  of  normal  skin  from  the  chin  with  its  pedicle  above  at  the  edge  of 
the  defect.  This  flap  was  turned  up  and  used  to  line  the  lip,  and  lateral 
flaps  from  the  cheek  were  shifted  in  to  cover  it. 

In  defects  of  this  character  one  mav  utilize  the  scar  tissue  to  line 


SURGERY    OF    THE    LIPS 


539 


the  lip.  This  was  first  carried  out  by  Berger.  He  dissected  up  a 
flap  of  the  scar  with  its  base  above  and  turned  it  upward  to  line  the  lip. 
A  pedunculated  flap  from  the  arm  was  then  used  to  cover  the  raw 
surface. 

The  use  of  scar  tissue  to  line  the  lip  is  a  doubtful  procedure 
because,  in  order  to  insure  circulation,  it  must  be  cut  so  thick  that  a 
rigid  flap  is  formed  which  is  difficult  to  handle.  One  is  nearly  always 
tempted  to  try  this  method  as  it  is  apparently  so  simple,  but  here  also 
the  rule  applies  that  scar  tissue  flaps  are  inadvisable  whenever  normal 
tissue  is  available.  In  addition  the  liability  to  infection  around  the 
mouth  makes  the  successful  use  of  this  poorly  nourished  tissue  largely 
a  matter  of  chance. 


Fig.  619. — Restoration  of  the  lower  lip  for  a  defect  following  X-ray  treatment. — i, 
2  and  3.  Condition  of  the  patient  when  she  came  under  my  care,  following  intensive  X-ray 
treatment.  The  entire  lip  is  destroyed  with  the  exception  of  a  small  tag  of  vermilion  border, 
which  can  be  seen  in  3.  The  chin  and  adjacent  portions  of  the  cheek  are  covered  with 
dense  scar  tissue.      The  lower  teeth  are  on  a  bridge. 


On  the  whole  it  is  better,  whenever  possible,  to  excise  the  scar  tissue 
and  to  shift  in  normal  tissue.  In  certain  extensive  burns  involving  the 
face  and  neck,  there  is  no  normal  tissue  available  from  the  immediate 
neighborhood,  and  for  these  the  Italian  method  should  be  used.  It  has 
been  said  that  the  lip  has  little  function  when  the  defect  is  closed  by  the 
Italian  method,  but  although  this  is  true  to  a  certain  extent,  I  have 
found  that  if  the  edges  are  carefully  freed  from  scar  and  the  ends  of  the 
muscles  of  lip  and  cheek  are  sutured  to  the  double  faced  flap,  the  func- 
tion of  the  lip  will  be  satisfactory. 

The  following  history  with  operative  notes  will  explain  a  method 
by  which  I  was  able  to  reconstruct  a  lower  lip. 

The  patient  who  was  30  years  old,  had  been  treated  over  zealously 


540 


PLASTIC    SURGERY 


with  X-rays  for  angioma  of  the  Up.     About  150  treatments  had  been 
given  and  the  result  was  satisfactory  so  far  as  removing  the  angioma 


Fig.  620. — Restoration  of  the  lower  lip,  continued. — i,  2  and  3.  Taken  seven  months 
after  removal  of  the  greater  portion  of  the  scar  tissue  and  shifting  up  a  double-pedicled 
flap  from  the  skin  of  the  neck.  Compare  with  Fig.  619.  Note  the  difference  in  the  tissue 
covering  the  chin.      In  3  can  be  seen  the  remains  of  an  angioma  on  the  left  cheek. 

was  concerned,  but  unfortunately  at  the  same  time  the  greater  portion 
of  the  lower  lip  and  the  adjacent  soft  parts  of  the  chin  and  cheek  had 
been  destroyed.     Several  operations  under  general  and  local  anesthesia 


Fig.  621. — Restoration  of  the  lower  lip,  continued. —  i,  2  and  3.  One  month  later. 
The  lip  was  lined  (over  the  bridge)  with  material  from  each  side  and  the  flap  from  the  chin 
was  shifted  up  to  cover  it.  The  vermilion  border  was  formed  by  splitting  the  patch  pre- 
viously mentioned,  and  suturing  it  to  the  border  of  the  newly  formed  lip.  The  defect  on 
the  chin  was  covered  with  another  double-pedicled  flap  from  the  neck.  Note  the  small 
amount  of  scar  tissue  remaining  and  the  inconspicuous  scars  on  the  neck.  Partial  excision 
of  the  angioma  of  the  left  cheek  has  also  been  done. 

had  been  done  (pedunculated  flaps  from  the  arm,  etc.)  before  the  patient 
came  under  mv  care.     The    condition   on  admission  was  as  follows: 


SURGERY    OF    THE    LIPS 


541 


The  lower  lip  except  for  a  tag  of  the  vermilion  border  on  the  left  side 
near  the  angle,  was  missing.  The  entire  chin  and  neighljoring  i)()rtions 
of  the  cheek,  especially  on  the  left  side,  were  covered  with  scar  tissue. 
In  talking  or  eating  saliva  constantly  drooled  out  of  the  defect,  and  the 
patient  was  compelled  to  plug  the  space  with  a  dressing  to  prevent  this 
inconvenience. 

The  lower  teeth,  which  had  also  been  destroyed,  had  been  rei)laced 
by  a  bridge  with  very  long  incisors  and  canines,  as  can  be  seen  in  the 
plates. 

First  Operation. — The  problem  was  to  replace  the  scar  tissue  on 
the  chin  and  cheek  with  normal  skin  before  attempting  the  reconstruc- 


I  2  3 

Fig.  622. — Restoration  of  the  lower  lip,  continued. —  i,  2  and  3.  Four  months  after 
construction  of  the  lip.  Note  the  shape  of  the  chin  and  lip.  The  angioma  has  also  been 
completely  removed  during  this  time.  Several  secondary  shaping  operations  had  been 
done.  The  result  of  the  operations  was  the  relief  of  a  hideous  deformity  and  the  control 
of  the  constant  drooling.  This  patient  had  been  operated  on  a  number  of  times  before 
coming  under  my  care  and  refused  to  consider  the  use  of  a  pedunculated  flap  froin  a  distant 
part,  as  this  had  been  tried  several  times  without  success. 

tion.  The  scar  was  dissected  up  from  the  chin  with  its  pedicle  at  the 
margin  of  the  defect,  and  sutured  into  position,  skin  side  inward,  in 
order  to  gain  as  much  as  possible  from  its  use.  The  lateral  areas  of 
scar  were  then  removed  from  the  cheek  and  a  double-pedicled  bridge 
flap  was  dissected  up  from  below  the  chin  and  shifted  upward  to  cover 
the  chin  and  adjacent  raw  areas.  This  flap  covered  the  base  of  the  scar 
tissue  flap  without  difliculty,  and  was  sutured  into  position.  The 
defect  below  the  chin  was  made  quite  small  by  undercutting  and  sliding 
up  the  neck  skin.  In  due  time  the  greater  portion  of  the  scar  flap 
sloughed,  but  the  bridge  flap  lived  and  the  chin  was  covered  with  thick 
skin  and  subcutaneous  tissue.  The  defect  was  thus  considerably  re- 
duced in  size. 


542  PLASTIC    SURGERY 

The  patient  was  then  sent  home  with  instructions  to  massage  the 
tissues,  and  after  six  months,  when  she  returned  for  further  treatment, 
the  skin  and  scar  had  been  thoroughly  loosened  and  were  movable 
everywhere.  The  defect  was  more  shallow  and  the  chin  and  greater 
portion  of  the  cheek  areas  previously  covered  with  scar  were  now  cov- 
ered w^th  soft  movable  skin,  and  in  every  way  conditions  for  the  recon- 
struction of  the  lip  were  more  favorable  than  before. 

Second  Operation. — The  tag  of  mucous  membrane  on  the  left 
side  was  spht  from  the  commissure  toward  the  midline,  but  not  com- 
pletely through,  so  that  when  it  was  shifted  with  the  flap  of  tissue  out- 
side of  it,  it  unfolded  and  the  outer  portion  with  the  skin  was  turned 
inward,  and  meeting  a  much  shorter  flap  from  the  other  side,  formed  the 
lining  of  the  lip.  This  was  bordered  by  the  vermilion  edge  which 
nearly  reached  across  the  lip.  The  bridge  flap  of  skin  previously 
placed  on  the  chin  was  then  loosened  and  after  excision  of  the  scar  in 
the  angles  was  shifted  upward  well  above  the  line  of  the  lower  teeth,  to 
cover  the  lining  flaps.  There  was  no  tension,  but  the  flap  was  held  in 
position  jvith  buried  sutures  of  catgut,  so  placed  as  to  give  it  support, 
and  the  mucous  flap  was  sutured  to  the  skin  along  the  lip  border.  The 
defect  below  was  then  covered  with  a  double-pedicled  flap  from  the 
neck  which  was  shifted  upward  and  sutured  to  the  lower  border  of  the 
upper  flap,  and  to  the  point  of  the  chin.  By  undercutting  down  to  the 
clavicle  on  each  side,  the  skin  of  the  neck  was  shifted  upward  and  all 
defects  were  closed.  Protective  drains  were  placed  in  the  lower  angles. 
All  wounds  healed  per  primam. 

Several  shaping  operations  were  subsequently  done.  The  scar 
on  the  neck  and  face  are  quite  inconspicuous,  and  in  comparison  with 
the  original  condition  there  is  marked  improvement. 

This  case  shows  the  advantage  of  preparing  the  surrounding  tissues 
before  undertaking  the  reconstructive  work.  As  a  rule,  there  is 
marked  shrinkage  of  the  double-pedicled  flaps  shifted  up  from  the  neck, 
but  in  this  case  by  first  shifting  the  flap  to  cover  the  chin,  and  allowing 
it  to  contract  in  that  position,  there  was  little  additional  shrinkage  when 
it  was  moved  upward  to  form  the  outside  of  the  lip.  The  color  of  the 
flap  matches  very  well  the  skin  of  the  face  and  on  the  whole  the  cosmetic 
and  functional  result  is  good. 

LESIONS  OF  BOTH  LIPS 

Extensive  Loss  of  Substance. — Where  there  is  a  defect  involv- 
ing both  lips  at  the  same  time,  it  is  probably  better  to  construct  each 


SURGERY    OF    THE    LIPS  543 

lip  separately.  However,  several  methods  have  been  used  for  making 
the  repair  simultaneously. 

]\Iontet  uses  quadrangular  Haps  from  the  cheek  and  chin.  The  inner 
border  of  each  flap  is  formed  by  the  defect  itself,  and  the  free  ends  by 
incisions  continuous  with  the  upper  and  lower  margins,  the  outer 
borders  by  incisions  parallel  to  the  edge  of  the  defect.  The  pedicles  of 
both  flaps  are  together  in  the  mid-portion  of  the  cheek.  The  flaps 
are  loosened  so  that  the  inner  borders  form  the  free  margin  of  the  lip, 
and  the  free  ends  of  the  flaps  are  sutured  to  the  freshened  edges  of 
the  upper  and  lower  lips. 

INIackensie  shifts  a  broad  flap  from  the  chin  and  neck  with  a  lateral 
pedicle.     The  flap  is  divided  lengthwise  and  shifted  upward,  the  upper 


^ 


El 

Fig.  623.  Fig.  624. 

Fig.  623. — Operation  for  the  reconstruction  of  both  lips  at  the  same  time  {Monlel). — 
The  flaps  are  raised  as  outlined.  The  upper  flap  is  shifted  downward  and  inward,  the  line 
CD  being  sutured  to  AB.  The  lower  flap  is  shifted  upward  and  inward,  the  line  EF  being 
sutured  to  GH. 

Fig.  624. — Operation  for  the  reconstruction  of  both  lips  at  the  same  time  (Mackensie). — 
The  upper  half  of  the  flap  is  shifted  upward  so  that  the  line  EF  may  be  sutured  to  AB  to 
form  the  upper  lip.  The  lower  half  is  shifted  upward,  GH  being  sutured  to  CD  to  form  the 
lower  lip. 

portion  being  sutured  to  repair  the  defect  in  the  upper  lip,  and  the  lower 
to  All  the  defect  in  the  lower  lip. 

Both  of  these  operations  are  undesirable  on  account  of  scars  and 
lack  of  sufficient  mucous  lining,  but  the  principles  may  be  useful  and 
should  be  borne  in  mind. 

Payan  (1839)  glides  forward  the  cheek  to  form  both  lips  at  the  same 
time,  and  makes  the  incision  which  is  to  form  the  mouth  before  sliding 
the  cheek  forward.  ]Morestin  uses  a  similar  procedure  but  makes  his 
incision  secondarily  after  the  cheek  has  been  shifted  forward. 

RECONSTRUCTION  OF  THE  VERMILION  BORDER 

Partial  Destruction. — Defects  in  the  vermilion  border  may  be 
quite  unsightly  and  call  for  operative  interference.  A  simple  method  is 
to  make  an  incision  of  sufficient  length  through  the  lip  parallel  to,  and 


544 


PLASTIC    SURGERY 


0.2  cm.  (}  12  inch)  below  the  mucocutaneous  junction.  Then  join  this 
with  an  incision  on  each  side  of  the  loss  of  substance  and  perpendicular 
to  the  free  border  of  the  lip.  In  this  way  two  square-ended  flaps  are 
formed  which  are  drawn  together  and  sutured. 


Pig.  625. — Operation  for  reconstruction  of  a  part  of  the  vermilion  border  {modified 
from  Nelaton  and  Ombredanne) . — i  and  2.  The  dark  lines  indicate  the  outline  of  the  flaps 
A  and  B.     They  are  shifted  inward  and.  sutured. 

Defects  of  a  considerable  width  may  be  closed  in  this  way,  as  the 
vermilion  border  is  very  extensible. 

Total  Destruction  of  the  Vermilion  Border  of  One  Lip. — For  the 

relief  of  this  condition  Dieffenbach,  after  freshening  the  defective  lip, 


A©k,^_^/cA 


V 


J   V^ 


Fig.  626. — Operation  for  the  reconstruction  of  the  vermilion  border  (Dieffenbach) . — i  and 
2.  The  lower  lip  is  freshened  and  a  small  flap  of  the  vermilion  border  is  taken  from  each 
side  of  the  upper  lip.  These  flaps  are  brought  down  and  sutured  together  to  form  a  border 
for  the  lower  lip.      If  too  much  constriction  follows,  the  commissures  may  be  lengthened. 

takes  a  flap  from  the  outer  third  of  the  vermilion  border  of  the  othei 
lip,  on  each  side,  and  sutures  it  to  complete  the  border  of  the  defective 


Pig.  627. — Operation  for  the  reconstruction  of  the  vermilion  border  (Tripier). — i  and 
2.  The  lower  lip  is  freshened  by  excision  of  the  area  between  the  points  A  and  B.  Then  a 
double-pedicled  flap  of  mucosa  CDEF  is  raised  from  behind,  and  is  shifted  forward  into  the 
defect.      The  raw  surface  left  by  raising  the  flap  is  closed  by  suture,  or  allowed  to  granulate. 

lip.     This  method  is  not  desirable  because  the  mouth  is  considerably 
shortened.     However,  this  shortening  can  be  subsequently  overcome , 
by  lengthening  the  commissures. 


SURGERY    OF    THE    LIPS 


545 


Berger  used  a  pedunculated  flap  of  the  mucous  membrane  of  the 
cheek  to  form  the  vermilion  border,  but  these  flaps  are  not  dependable. 
They  will  often  slough  when  used  for  this  purpose,  and  little  or  nothing 
will  be  gained. 


Fig.  628. — Operation  for  the  reconstruction  of  the  vermilion  border  (Schulten). — 
I  and  2.  The  double-pedicled  flap  X  is  raised  from  the  upper  lip  and  shifted  down  to 
fill  the  defect  in  the  lower  lip.  The  pedicles  are  divided  subsequently  if  necessary. 
3.  Note  the  thickness  of  the  flap. 

Double-pedicled  flaps  of  mucous  membrane  from  the  same  lip,  or 
from  the  normal  lip,  have  been  used  with  success.  Their  use  is  more 
likely  to  be  successful  than  the  methods  previously  mentioned. 

Tripier  used  a  flap  with  a  pedicle  on  each  end  obtained  from  the 
mucosa  of  the  same  lip  behind  the  defect,  and  shifted  it  forward  to 


123  4 

Fig.  629. — Operation  for  reconstructing  a  portion  of  the  vermilion  border  (Berger). — 
I.  The  dark  lines  indicate  the  incisions  liberating  the  extremities  of  the  vermilion  border 
A  and  B.  2.  A  is  sutured  to  B.  The  dark  triangles  beneath  indicate  defects  opening  into 
the  mouth.  The  flap  X  with  its  base  indicated  by  the  dotted  line,  is  turned  up  and  sutured 
to  the  under  surface  of  A  and  B.     3  and  4.   The  raw  surface  is  covered  by  the  flap  Y. 

fill  the  gap.  Schulten  used  a  flap  of  the  same  type,  although  consider- 
ably thicker  and  markedly  curved,  obtained  from  the  other  lip.  The 
pedicles  were  close  to  the  angles  and  the  flap  was  shifted  and  sutured 
into  the  defect.  The  raw  surface  from  which  the  flap  was  obtained 
was  closed  at  once.  If  any  redundant  tissue  in  the  region  of  the  pedicles 
proves  to  be  annoying  it  can  be  subsequently  removed. 

I  have  seen  one  case  of  complete  replacement  of  the  outer  edge  of 
35 


546 


PLASTIC    SURGERY 


the  red  border  of  both  hps.  with  scar  following  a  burn,  in  w^hich  the 
deformity  was  not  especially  marked  except  that  the  lips  were  abnor- 
mally white.  However,  when  the  patient  attempted  to  open  his  mouth 
wddely,  the  appearance  was  much  like  that  which  would  have  been 
caused  by  a  purse-string  suture,  an  opening  being  left  about  2.5  cm. 
(i  inch)  in  diameter.     This  deformity  was  completely  corrected  by  ex- 


/V'  \  /■  iA 


Fig.  630.  Fig.  631.  Fig.  632. 

Fig.  630. — Operation  for  loss  of  substance  of  the  commissure  (Erichsen) . — The  shaded 
area  is  the  shape  of  the  excision.     A  is  sutured  to  C,  and  B  to  D. 

Fig.  631. — Operation  for  loss  of  substance  of  the  commissure  {Serre). — The  excision  is 
made  in  the  form  of  a  half-star.     The  point  A  is  then  sutured  to  B. 

Pig.  632. — Operation  for  loss  of  substance  of  the  commissure  {Serve). — The  excision 
was  made  in  the  form  shown  by  the  shaded  areas.  The  point  G  was  sutured  to  D,  F  to 
C,  E  to  H,  thus  relieving  the  deviation  of  the  commissures. 

cision  of  the  scar  around  the  mouth,  shifting  forward  the  normal  mucous 
membrane,  and  suturing  it  to  the  skin. 

Partial  Reconstruction. — In  partial  reconstruction  of  the  lower  lip 
the  restoration  of  the  vermilion  border  is  of  the  greatest  importance. 
In  these  cases  it  may  be  of  advantage  to  utilize  flaps  of  scar  tissue  in 
lining  the  defect,  covering  the  surface  with  flaps  of  normal  tissue  from 


^^ 


Fig.    633. — Operation    for   deviation   of   the   commissure    (Szymanowski). — i  and    2.    The 
dark  line  indicates  the  incision.      The  flap  A  is  lowered  and  placed  above  the  flap  B. 

the  desired  region.  In  a  case  with  contracture  and  destruction  of  the 
vermilion  line  near  the  angle  of  the  mouth,  and  with  adherence  of  the 
lip  to  the  jaw,  Berger  was  able  to  restore  the  vermilion  line  by  dissect- 
ing out  the  ends  and  suturing  them  together.  In  this  way  he  formed  a 
sort  of  bridge  over  the  underlying  scar  which  opened  into  the  mouth. 
In  order  to  line  the  cavity  beneath  this  bridge,  he  then  cut  a  rectangular 


SURGERY    OF    THE    LIPS 


547 


flap  from  the  scar  below  with  its  base  at  the  defect  and  turned  it  up, 
and  after  separatin<,'  the  Hp  from  the  mandible,  sutured  it  to  the  mucous 
border  inside,  thus  lining  the  defect  below  the  vermilion  border.  The 
surface  was  covered  with  a  pedunculated  flap  from  the  chin. 

Slight  Loss  of  Substance  of  the  Commissure — Where  there  has 
been  loss  of  substance  of  the  mucosa  of  the  commissure  there  is  usually 
an  adhesion  of  the  lip,  and  a  consequent  partial  atresia.  The  loss  of 
substance  following  the  excision  of  a  tumor  has  been  corrected  bv  the 
formation  of  flaps  to  draw  the  commissure  outward. 

Serre  and  also  Erichsen  have  utilized  this  method,  and  I  have  found 
it  a  very  valuable  procedure.  The  diagrams  will  indicate  the  lines  of 
the  incisions. 

Deviations  of  the  Commissures. — In  contracted  scars  following 
burns  we  often  lind  the  commissures  either  pulled  downward  or  upward. 


Wu^.--^ 


Fig.  634. — Operation  for  the  correction  of  downward  deflection  of  the  commissure. — 
I.  The  dark  line  indicates  the  outline  of  the  flap  ABC.  2.  The  point  B  is  sutured  into  the 
slit  CD  at  D,  and  C  to  A. 


Many  methods  have  been  devised  for  overcoming  this  deformity. 
Some  of  these  operations,  such  as  that  of  Serre  for  raising  the  commis- 
sure, depend  on  the  excision  of  a  more  or  less  extensive  area  of  tissue, 
the  lines  of  which  are  so  planned  that  when  the  edges  are  approximated 
the  deformity  will  be  corrected. 

The  other  type  is  represented  by  the  operation  of  Szymanowski.  in 
which  the  commissure  is  raised.  In  this  operation  there  is  simply  the 
transposition  of  flaps  without  excision  of  tissue.  He  frees  the  vermilion 
border  and  then  raises  a  pedunculated  triangular  flap  from  the  cheek, 
its  tip  directed  toward  the  internal  angle  of  the  eye,  its  base  being  below 
the  ala.     This  flap  is  brought  down  and  sutured  above  the  red  border 


548  PLASTIC    SURGERY 

which  has  been  previously  freed,  the  tip  being  at  the  end  of  the  liberat- 
ing incision  near  the  midline.     All  other  wounds  are  then  closed. 


TO  RELIEVE    CONSTRICTION   OF   THE   BUCCAL    ORIFICE 

(MICROSTOMIA) 

In  some  instances  following  ulceration  (tuberculous,  syphilitic,  or 
occasionally  small-pox)  or  burns,  the  buccal  orifice  is  narrowed  without 
any  important  destruction  of  the  lining  membrane. 

In  these  cases,  which  may  vary  in  extent  from  partial  occlusion  to 
almost  complete  closure  of  the  mouth,  there  is  more  or  less  difficulty 
in  introducing  and  masticating  food,  in  keeping  the  mouth  clean,  and 
furthermore  there  is  more  or  less  marked  deformity. 


V 


y( 


V   *^    ^ 


3 
Pig.   635. — Operation  for  the  relief  of  constriction  of  the  buccal  orifice  (Werneck). — 
I.    The  dark  line  indicates  the  incisions  for  the  removal  of  the  skin  and  scar  tissue.      2. 
The  incisions  through  the  mucosa.     3.   The  flaps  of  mucosa  sutured  to  the  skin  to  form 
the  borders  of  the  lips. 

Dilatation  has  been  tried  thoroughly,  but  has  proved  useless.  Sim- 
ple division  of  the  angles  without  suture  was  also  tried  at  one  time,  but 
was  always  followed  by  a  prompt  recurrence. 

The  cheek  has  been  perforated  on  each  side  in  the  situation  of  the 
proposed  commissure,  and  a  lead  or  silver  ring  inserted.  After  healing 
was  complete  the  tissues  were  divided  to  this  point.  This  method  is 
slow  and  unsatisfactory. 

In  the  correction  of  this  deformity  some  plastic  operation  should  be 
utilized  in  which  the  epidermizatioh  will  be  prompt  and  the  chance  of 
recurrence  eliminated. 

Werneck's  Operation  (1817). — A  narrow  ellipsoid  incision  of  the 
desired  length  (the  ends  of  which  are  square)  is  made  transversely  to 
surround  the  contracted  orifice.     All  the  skin  included  in  this  area  is 


SURGERY    OF    THE    LIPS 


549 


excised,  care  being  taken  not  to  cut  through  the  mucosa.  The  latter 
is  then  divided  horizontally  in  the  midline  from  the  opening  to  the 
commissure,  and  the  edges  are  sutured  to  the  skin. 


Fig.  636. — Operation  for  the  relief  of  constriction  of  the  buccal  orifice  {Dieffenhach). — 
I.  The  skin  has  been  excised.  The  dark  lines  indicate  the  formation  of  the  flap  of  mucosa. 
Note  the  triangular  flaps  to  line  the  commissures.  2.  The  skin  and  mucosa  sutured 
together  to  form  the  commissures  and  lip  borders. 

Dieft'enbach  employed  a  similar  method,  but  instead  of  dividing  the 
mucosa  completely  back  to  the  commissure,  he  made  use  of  a  Y-shaped 
incision  leaving  a  triangular  flap  of  mucosa  at  the  commissure  which 


/ 


Fig.  637. — Combination  operation  for  the  relief  of  constriction  of  the  buccal  orifice 
{modified  from  Xelaton  and  Ombredanne). —  i.  Outline  of  skin  flaps.  2.  Skin  flaps  raised 
and  mucous  membrane  divided. 

was  brought  forward  and  sutured  to  the  skin,  thus  assuring  a  more 
stable  and  comfortable  ande. 


Fig.  638. — Combination  operation  for  the  relief  of  constriction  of  the  buccal  orifice, 
cdntinued. —  i.  The  mucosa  flaps  sutured  to  the  skin  to  form  the  lip  borders.  2.  The  skin 
flaps  after  being  shortened  are  turned  in  to  line  the  commissures. 

Werneck  subsequently  formed  the  commissure  by  turning  in  a  flap 
of  skin  after  excising  the  mucosa.  In  this  operation  he  did  not  utilize 
the  mucosa  as  in  his  first  operation. 

I  have  had  excellent  results  with  Dieft'enbach's  triangular  flap  of 
mucosa  to  form  the  commissures.     Nevertheless,  there  is  much  to  be 


S50 


PLASTIC    SURGERY 


said  in  favor  of  forming  the  commissures  from  small  skin  flaps  which 
are  turned  in  and  sutured  to  the  mucosa  within.  At  the  same  time  the 
mucosa  which  is  behind  the  constricted  portion  should  be  utilized  in 
covering  the  margin  of  the  lips.     In  other  words,  a  combination  of 


Fig.  639. — Result  of  enlarging  the  buccal  orifice  after  atresia  following  a  burn  of  the 
mucous  membrane. — i  and  2.  The  outer  margin  of  the  vermilion  border  around  the  entire 
mouth  had  been  burned,  together  with  the  surrounding  skin.  The  mouth  could  be  opened 
only  wide  enough  to  admit  a  teaspoon.  The  constriction  being  somewhat  like  a  puckering 
string.  The  photographs  were  taken  six  months  after  the  excision  of  the  constricting  band, 
with  plastic  reconstruction  of  the  commissures  and  vermilion  border. 

Werneck's  first  and  second  operations  seems  to  be  the  best  for  assuring 
the  commissures  and  avoiding  recurrence.  I  have  not  found  any  group 
of  patients  who  are  more  grateful  than  those  who  have  been  relieved 
from  marked  atresia  of  the  mouth. 


Fig.  640. — Microstomia  following  severe  infection. — i.  Note  the  shortening  of  the 
upper  lip  and  the  narrowing  of  the  mouth.  2.  Result  of  lengthening  the  upper  lip  by 
shifting  in  lateral  flaps.  The  angles  of  the  mouth  were  then  lengthened,  and  the  com- 
missures were  lined  with  mucous  membrance. 


Another  type  of  narrowing  of  the  buccal  orifice,  which  follows  noma, 
is  more  difficult  to  correct.  There  is  loss  of  substance  and  destruction 
of  the  neighboring  buccal  mucosa.     The  orifice  is  narrowed  and  the 


SURGERY    OF    THE    LIPS  55 1 

cheeks  are  bound  down  to  the  jaws  by  dense  cicatricial  bands  which 
lock  them.  The  adherent  portions  must  be  separated  and  the  cheek 
lined  by  one  of  the  procedures  described  elsewhere.  The  mouth  may 
then  be  made  as  broad  as  is  desired. 

ABNORM.\LLY  LARGE  MOUTH  (MACROSTOMIA) 

The  mouth  may  be  abnormally  large  fcongenitally)  and  in  some 
cases  it  is  necessary  to  reduce  the  distance  between  the  commissures. 
A  slight  correction  may  be  accomplished  by  making  a  V-shaped  incision 
on  each  side  through  the  full  thickness  of  the  cheek  at  the  proper  dis- 
tance from  the  angles.  The  apex  should  be  outward  and  on  a  level  with 
the  commissures.     The  triangular  flap  between  the  legs  of  the  V  is 


Fig.  641. — Deformity  following  luetic  ulceration  of  the  mouth. — i.  The  ulcer  in  its 
active  state.  2  and  3.  Taken  eighteen  months  later,  after  salvarsan  and  local  treatment. 
Note  the  enormous  size  of  the  mouth  and  the  extensive  infiltration  with  scar  tissue. 

then  shifted  toward  the  median  line,  and  the  wound  is  sutured  in  the 
shape  of  a  Y.  In  marked  cases,  whether  congenital  or  acquired,  it  is 
necessary  to  separate  the  tissues  and  suture  them  in  layers — mucous 
membrane  to  mucous  membrane,  etc.  Great  care  should  be  taken  to 
line  the  newly  constructed  commissures  with  mucous  membrane  or 
skin. 

ECTROPION  OF  THE  LIPS 

By  ectropion  is  meant  the  eversion  of  the  free  border  of  the  lip  so 
that  the  mucosa  is  permanently  exposed  to  the  air^.     The  deformity  is 


552 


PLASTIC    SURGERY 


usually  caused  by  contracted  scar  on  the  skin  surface  of  the  lip.  Every 
gradation  is  encountered,  from  partial  eversion  of  a  portion  of  the  lip 
to  complete  eversion  of  the  whole  lip,  so  that  the  entire  mucous  lining 
is  exposed  to  the  air. 


i 


Fig.  642. — Deformity  following  luetic  ulceration,  continued. — i  and  2.  No  attempt  was 
made  to  remove  the  scar  tissue  at  this  time,  this  being  reserved  for  a  subsequent  operation. 
The  mucous  membrane  was  loosened  above  and  below.  The  commissure  was  lined  with  a 
flap  of  mucosa  which  was  especially  broad  at  the  point  selected  for  the  angle  of  the  mouth. 
The  scar  tissue  with  some  normal  tissue  was  freed,  and  shifted  into  position,  an  effort 
being  made  to  reconstruct  the  cheek  on  that  side.      The  result  is  shown  in  the  photograph. 


In  old  cases  the  alveolar  margin  may  also  be  everted  and  the  teeth 
project  forward.     The  bone  is  atrophied,  and  the  teeth  are  usually 


k^J^\ 


Fig.  643. — Operation  for  the  relief  of  ectropion  of  the  upper  lip  (Behrend). — i.  A 
narrow  ellipse  of  tissue  is  excised  transversely  through  the  full  thickness  of  the  lip.  2. 
The  lip  is  drawn  down  and  the  wound  is  sutured  vertically. 

decayed,  there  is  constant  drooling  of  saliva,  and  in  extensive  cases 
the  deformity  is  revolting. 

Ectropion  of   the  lips  is  often   associated  with   contracted  scarsj 
involving  the  neck  with  the  fixed  point  on  the  clavicle  or  chest.     Inj 


SURGERY    OF   THE    LIPS 


553 


these  cases  the  head  is  bent  forward,  and  I  have  sometimes  seen  the 
everted  lower  lip  covering  the  sternal  notch. 

Ectropion  of  the  Upper  Lip. — Ectropion  is  much  less  frequently  found 
in  the  upper  than  in  the  lower  lip.  In  the  less  extensive  eversions 
Behrend's  operation  may  be  useful.  He  excises  a  narrow  ellipse  of 
tissue  transversely  through  the  full  thickness  of  the  lip.  about  midway 


Fig.  644. — Operation  for  the  relief  of  ectropion  of  the  upper  lip  (Teale). —  r.  The  dark 
lines  indicate  the  incisions  made  to  form  the  flaps.  2.  The  lip  is  pulled  down.  The  triangle 
ABC  is  superimposed  over  the  triangle  DHE.  The  point  H  being  sutured  at  C  and  the 
point  B  at  D. 

between  the  nose  and  the  lip  margin.     After  loosening  the  tissues  he 
sutures  the  wound  vertically  and  in  this  way  lowers  the  margin. 

Teale's  Operation. — Two  very  oblique  and  almost  horizontal  inci- 
sions are  made  through  the  lip.  These  cut  each  other  in  the  midline, 
thus  forming  tw^o  triangles  with  their  apices  at  the  middle  of  the  lip. 
The  flaps  are  loosened,  shifted  inward,  and  superimposed,  so  that  each 


Fig.  64.5. — Blasius- Wharton  Jones'  operation  for  the  relief  of  partial  ectropion  of  the 
lower  lip. — i  and  2.  The  dark  line  indicates  the  V-shaped  incision.  The  lip  is  liberated, 
the  wedge  of  tissue  A  is  shifted  upward,  and  the  wound  is  closed. 

apex  is  sutured  to  the  base  of  the  opposite  triangle.  In  this  way  the 
lip  is  lengthened  and  the  margin  lowered.  The  difliculty  is  that  the 
tips  of  the  long  narrow  triangles  may  slough,  but  despite  this  good 
results  may  be  obtained. 

Szymanowski  liberates  the  margin  of  the  lip  by  a  transverse  incision 
and  lowers  it,  and  then  fills  this  opening  by  using  a  flap  from  the  cheek 
on  each  side.     In  my  own  experience,  in  pronounced  cases,  the  use  of  a 


554 


PLASTIC    SURGERY 


double-faced  pedunculated  flap  from  the  arm  has  proved  the  method  of 
choice.  The  use  of  flaps  from  the  forehead  has  not  proved  satisfactory. 
Ectropion  of  the  Lower  Lip  (Partial)^ — Where  the  ectropion  is 
slight  and  involved  only  a  portion  of  the  vermilion  border,  Blasius's  or 
Wharton  Jones'  operation  is  often  sufficient.     The  cicatrix  is  loosened 


Fig.  646. — Operation  for  the  relief  of  partial  ectropion  of  the  lower  lip  {modified  from 
Nelaton  and  Ombredanne). — i  and  2.  The  dark  line  indicates  the  incision.  The  lip  is 
liberated  and  raised.  AB'  is  sutured  to  AC,  being  buttressed  on  the  triangle  of  tissue  BXC. 
The  flaps  BDFK  and  CEHL  are  shifted  inward  and  sutured. 

by  means  of  a  V-shaped  incision  of  suiflcient  width  and  the  vermilion 
border  is  restored  to  its  proper  position.  (I  have  found  over-correction 
to  be  advisable  in  these  cases.)  The  wound  is  then  sutured  so  that  it 
will  assume  the  shape  of  a  shallow  Y  or  T. 

Nelaton  and  Ombredanne  use  a  much  more  complicated  incision  for 
the  same  purpose  which  gives  a  fixed  point  on  which  the  tissue  to  be 


Pig.  647. — Contracture  of  the  chin  with  ectropion  of  the  lip  following  a  burn.  Dura- 
tion nineteen  months. — i  and  2.  A  thick  keloid-like  scar  involves  the  lips,  chin  and  cheeks. 
3.  The  scar  on  the  chin  was  excised  and  a  flap  from  the  neck  with  pedicle  below  was  shitted 
upward  and  sutured  to  the  lip. 

shifted  upward  may  be  supported.     The  technic  can  be  clearly  under- 
stood from  the  diagram. 

All  varieties  of  incisions  have  been  made  for  relieving  the  eversion 
and  each  case  will  require  the  one  appropriate  to  it.  Those  that  I 
have  mentioned  may  be  regarded  simply  as  suggestions.  Skin  grafts 
have  been  used  to  fill  the  defects  after  relief  of  the  ectropion,  and 


SURGERY    OF    THE    LIPS 


.">^:> 


Fig.  648. — Contracture  of  the  chin,  continued. —  i.  Profile  view  of  the  flap  with  pedicle 
below.  2.  Seven  months  later  the  pedicle  was  cut  and  the  flap  was  shifted  upward.  The 
defect  below  was  closed  by  undercutting  and  sliding.  3  and  4.  Three  years  later  the  angles 
of  the  mouth  were  raised  and  the  scar  on  the  neck  was  excised.  The  use  of  a  flap  from 
the  neck  of  this  type  is,  as  a  rule,  not  to  be  advised.  However,  by  waiting  until  it  is 
thoroughly  contracted  and  then  dividing  it  transversely  and  shifting  it  upward  as  far  as 
desired,  it  can  be  utilized  with  success. 


Fig.  649. — Ectropion  of  the  lower  lip  with  involvement  of  the  neck  and  cheek  follow- 
ing a  burn.  Duration  eight  months. —  i  and  2.  Note  the  greater  involvement  of  the  right 
side.  3.  A  close  view  of  the  pedunculated  flap  from  the  arm  sutured  to  the  left  cheek, 
with  horsehair  stitches  still  in  place. 


Fig.  650. — Ectropion  of  the  lower  Hp,  continued. — i.  The  cast  in  place.  Note  the 
position  of  the  arm  and  freedom  of  the  face  and  mouth.  2.  After  removal  of  the  cast, 
the  flap  can  be  seen  still  attached  to  the  arm  before  division  of  the  pedicle. 


556 


PLASTIC    SURGERY 


occasionally  give  good  results.     A  graft  of  whole-thickness  skin  is  to 
be  preferred. 

In  some  cases  the  Indian  method  may  be  used  to  advantage  in  con- 
junction with  the  foregoing  procedures. 


Fig.  651. — Contracture  of  the  mouth  and  chin  following  a  burn. — i.  The  dense  scar 
surrounding  the  mouth  and  involving  the  cheeks,  chin  and  nose.  Note  the  extent  of  ability 
to  open  the  mouth.  2.  Result  of  operations  to  temporarily  relieve  the  contracture  of  the 
mouth.  3.  Inasmuch  as  extensive  visible  scars  had  to  be  avoided  in  this  case  a  flap  was 
raised  from  the  abdominal  and  chest  wall  with  its  pedicle  above,  and  an  attempt  was  made 
to  insert  the  free  end  of  this  flap  into  an  incision  near  the  clavicle,  and  later  to  cut  the 
lower  pedicle  and  by  the  same  process  to  finally  raise  the  flap,  so  that  it  could  cover  the 
chin.  This  procedure  was  a  failure  for  several  reasons  and  the  original  pedicle  was  never 
severed.      Then  the  under  surface  was  grafted  and  the  patient  was  sent  home. 

Complete  Ectropion. — In  the  very  extensive  cases,  of  all  the  many 
methods  suggested,  only  one  is  worth  trying,  although  it  is  usually 
resorted  to  only  after  long  temporizing.  Of  course  if  the  head  is  drawn 
forward  and  the  ectropion  is  due  to  estensive  involvement  of  the  neck 
as  well  as  of  the  chin,  the  correction  of  the  contracture  of  the  neck 


Fig.  652. — Contracture  of  the  mouth  and  chin,  continued. — i.  The  flap  on  the  chest 
wall  nine  months  later.  Note  the  contracture  of  the  grafted  surface.  2.  This  was  easily 
straightened  on  account  of  the  thick  underlying  pad  of  fat,  and  the  freshened  edge  was 
inserted  into  an  incision  on  the  radial  side  of  the  wrist  and  forearm,  and  after  tw'o  weeks 
the  pedicle  was  cut  from  the  chest  wall  and  the  flap  was  nourished  from  the  forearm.  3. 
The  scar  on  the  forearm  after  transfer  of  the  flap  to  the  chin. 

must  first  be  looked  after.  (See  Chapter  on  the  Neck.)  The  use  of  a 
flap  from  the  arm,  either  by  double  or  single  transfer,  is  the  method  of 
choice.  The  procedure  which  I  have  found  most  satisfactory  is  as 
follows: 


SURGERY    OF    THE    LIPS 


557 


The  entire  mucosa  is  loosened  and  turned  upward.  Tt  is  usually 
found  to  be  hypertrophied  and  it  may  be  necessary  to  trim  the  edges. 
The  scar  on  the  chin  is  then  dissected  up  from  above  downward  as  a 
flap,  the  dissection  being  complete  on  the  side  opposite  the  arm  from 
which  the  flap  is  to  be  obtained.     The  scar  on  the  same  side  as  the  arm 


Fig.  653. — Contracture  of  the  mouth  and  chin,  continued. — i.  The  flap  on  the  forearm 
attached  to  the  chin.  2.  Two  weeks  later  the  flap  was  cut  away  from  the  forearm.  3. 
The  flap  two  weeks  after  final  suturing  covering  the  entire  chin. 

to  be  used  is  not  completely  removed  (if  it  is  extensive)  because  it  is 
not  possible  to  suture  the  pedicle  of  the  flap  closely  to  this  area.  It  is 
better  to  wait  until  the  pedicle  is  cut  and  then  remove  that  portion  of 
the  scar,  and  lit  in  the  pedicle.     All  undamaged  muscle  tissue  should 


Fig.  654. — Contracture  of  the  mouth  and  chin,  continued. — i.  Profile  view  of  the 
patient  two  weeks  after  final  suturing.  2.  Result  four  and  a  half  years  after  implantation 
of  the  flap  on  the  chin.  Several  secondary  operations  were  done  during  this  period.  Xote 
the  appearance  of  the  chin  and  the  normal  .size  of  the  mouth.  In  transplanting  this  flap 
an  interval  was  always  allowed  to  elapse  between  the  cutting  of  the  pedicles  and  the  further 
transfer  of  the  flap.  In  this  way  all  necrotic  tissue  was  taken  care  of  and  shrinkage  took 
place.  In  consequence,  there  has  been  no  shrinkage  of  the  flap  since.  The  color  of  the 
flap  matches  the  adjacent  skin  exactly  and  the  result,  as  far  as  the  chin  and  lip  is  concerned, 
is  excellent. 

be  preserved  in  the  dissection.  A  carefully  calculated  flap  of  sufflcient 
size  and  proper  shape  is  then  raised  from  the  arm  and  sutured  into  the 
defect;  the  suturing  should  be  as  accurate  as  possible,  especially  along 
the  vermilion  border.  The  scar  tissue  flap  below  may  be  trimmed 
and  the  edge  sutured  to  the  arm  flap ;  or  the  arm  flap  may  be  sutured  to 


558 


PLASTIC    SURGERY 


the  base  of  the  inner  surface  of  the  flap  of  scar  which  is  then  brought 
up,  so  that  it  overlaps  the  arm  flap.     Every  portion  which  by  this 


Fig.  655. — Ectropion  of  the  lower  lip  caused  by  contracture  following  a  burn.  Dura- 
tion eight  years. — i.  Note  almost  complete  eversion  of  the  lower  lip.  Also  the  involve- 
ment of  the  entire  skin  of  the  face  with  scar  tissue.  2.  The  plaster  cast  which  immobilizes 
the  arm  and  head  while  a  flap  from  the  arm  is  being  transferred  to  the  chin.  3.  The  flap 
still  attached  to  the  arm  and  adherent  to  the  chin.      Two  weeks  after  operation. 

time  definitely  shows  a  lack  of  blood  supply  is,  of  course,  trimmed  off. 

Horsehair  and  silkworm  gut  is  the  suture 
material  of  choice.  Drainage  is  estab- 
lished at  dependent  portions,  and  the 
arm  is  secured  in  a  plaster  cast  so  that 
there  is  no  tension  on  the  flap.  In  from 
ten  to  fourteen  days  the  pedicle  is  cut, 
and  the  arm  -is  lowered.  The  scar  be- 
neath the  pedicle  of  the  flap  is  then  ex- 
cised and  the  pedicle  is  fitted  in.  One 
of  the  methods  previously  described  for 
conserving  the  circulation  of  the  arm 
flap,  and  at  the  same  time  permitting 
shrinkage  before  transplantation,  is  well 
worth  considering,  and  in  many  casesj 
will  save  time. 

I  have  been  quite  successful  in  raising 
a  flap  from  the  abdomen  and  grafting 
the  under  surface.     Then  after  several 

months  I  have  transplanted    this    flap    into  the  forearm  and  subse- 


FiG.  656. — Ectropion  of  the 
lower  lip,  continued. —  i  and  2.  One 
year  after  the  implantation  of  the 
flap  from  the  arm. 


SURGERY    OF    THE    LIPS 


559 


quently,  after  severing  the  pedicle  from  the  abdomen  and  allowing  the 
circulation  to  completely  adjust  itself,  have  transferred  it  to  the  chin 
and  lip,  after  freshen ii^j;  the  under  surface. 


Fig.  657. — Ectropion  of  the  lower  lip  following  a  burn  eleven  years  previously. —  i. 
This  case  is  shown  in  order  to  emphasize  the  difficulties  sometimes  encountered  in  securing 
normal  skin  for  flaps.  The  entire  face  and  neck,  the  upper  portion  of  the  chest  and  back, 
and  both  upper  e.xtremities  to  the  finger  tips  are  covered  with  scar  tissue.  2.  The  lower 
lip  is  everted  and  the  photograph  is  taken  with  the  lip  held  as  high  as  possible. 

I  have  used  the  arm  flap  in  children  as  young  as  three  years,  and 
find  that  they  do  not  mind  the  enforced  position  after  the  tirst  day. 

Several  secondary  shaping  operations  may  be  necessary  to  raise 
or  lower  the  angles,  to  make  the  vermilion  line  svmmetrical.  and  to 


Fig.  658. — Ectropion  of  the  lower  lip,  continued. — Result  of  using  a  double-pedicled 
flap  of  scar  tissue  for  the  relief  of  ectropion,  i.  One  week  after  the  e.xcision  of  the  dense 
scar  on  the  chin  and  relief  of  the  ectropion.  The  double-pedicled  flap  has  been  shifted 
upward  and  covers  the  chin.  2  and  3.  Result  one  year  after  operation.  There  has  been 
considerable  improvement  and  the  tissue  on  the  chin  is  of  better  quality  than  that  removed 
at  operation.      Much  more  can  now  be  done  to  improve  the  present  condition. 

excise  any  scar  tissue  that  may  have  been  overlooked,  but  the  ultimate 
results  are  most  satisfactory.  The  flap  may  be  too  thick,  especially 
if  a  double  transfer  from  the  abdomen  is  used,  but  the  excess  fat  can 
be  removed  without  difficulty.  The  tendency  of  these  flaps  is  to  lessen 
in  thickness  as  time  goes  on,  and  with  the  excision  of  the  surrounding 


560  PLASTIC    SURGERY 

scar  and  the  gradual  stretching  of  the  flap,  what  appears  to  be  an  ex- 
cessive thickness  is  soon  reduced. 

There  is  usually  some  slight  infection  along^the  suture  line  in  all  o': 
these  cases,  and  for  this  reason  I  prefer  the  interrupted  on-end  mattress 
suture,  so  that  the  removal  of  one  or  two  stitches  will  not  afifect  the 
others.  It  is  most  important  that  all  hemorrhage  be  checked  before 
the  flap  is  transplanted. 

The  utility  of  Ollier-Thiersch  grafts  on  the  chin  for  the  relief  of 
contracture  is  doubtful.  t. 

Ectropion  of  the  mucous  membrane  is  usually  congenital,  and  is  due 
to  hypertrophy  of  the  mucous  and  submucous  tissue.     I  have  been  able 
to  correct  this  type  of  eversion  of  the  entire  vermilion  border  on  both 
upper  and  lower  lips,  by  the  excision  of  an  elliptical  piece  of  mucous  j 
membrane  and  submucous  tissue  taken  transversely  from  the  inside  of 

fi' 

4-, 


I  2 

Pig.  659. — Redundant  mucous  membrane  of  the  lip. — i.  The  redundant  mucosa  can 
be  seen.  It  extends  the  full  length  of  the  upper  lip  and  is  much  less  tightly  drawn  than  the 
vermilion  border.  There  is  also  slight  notching  in  the  midline  of  the  lip.  2.  A  large  ellipse 
of  mucosa  was  removed  transversely,  and  two  small  areas  of  similar  shape  were  excised 
at  right  angles  to  it.      Photograph  taken  eight  months  after  operation. 

the  lip.  In  addition,  when  the  tissue  is  very  redundant,  I  find  that  tho 
excision  of  areas  of  suitable  shape  at  right  angles  to  the  ellipse  alreadV 
mentioned  will  aid  materially  in  correcting  the  deformity  (Fig.  659). 


CHEILORRHAPHY  (SUTURING  THE  LIPS  TOGETHER) 

Abbe  in  1898  held  the  lips  together  by  sutures  without  freshening 
the  edges  as  a  secondary  procedure  in  his  operation  for  widening  the 
upper  lip.  Morestin  in  January,  1913,  reported  that  he  had  sutured 
portions  of  the  lips  together  as  a  temporary  measure  in  certain  plastic 
operations  around  the  mouth.  He  has  again  brought  this  procedure 
into  prominence,  and  has  found  it  most  useful  in  reconstructive  work 
following  war  wounds  in  this  region. 

The  lips  may  be  united  from  the  midline  nearly  to  the  commissure  on 
one  side.  The  mid-portion  of  the  lips  may  be  united  for  the  full  extent 
except  for  a  short  distance  at  each  angle.     The  union  may  be  used  to 


SURGERY    OF    THE    LIPS  56 I 

maintain  the  good  position  of  the  Up  which  has  already  been  repaired; 
■n  atypical  plastic  operations  on  the  lips  and  for  eversions  following 
urns. 

Tecknic. — Under  a  local  anesthetic  the  free  border  of  each  lip  is 
divided  (along  the  selected  portion)  by  an  incision  0.5  cm.  (15  inch) 
deep  near  the  anterior  margin  of  the  vermilion  border.  Buried  sutures 
of  catgut  are  used  to  unite  the  raw  surfaces,  and  horsehair  or  fine  silk 
for  the  skin.  Adhesions  should  be  freed  before  the  incisions  are  made, 
'"he  commissures  should  not  be  disturbed  unless  they  are  implicated, 
■/he  non-absorbable  sutures  are  removed  after  eight  days. 

To  separate  the  lips,  a  sound  or  curved  clamp  having  been  passed 
behind  the  line  of  union,  they  are  carefully  divided  and  the  wound  in 
each  lip  is  sutured. 

Cheilorrhaphy  is  usually  done  as  a  preliminary  to  plastic  recon- 
tructive  work,  the  lips  being  left  attached  for  months  if  necessary. 

e  border  of  the  incomplete  lip  may  be  sutured  to  the  opposite  lip,  or 
ciie  newly  formed  lip  may  be  sutured  to  the  opposite  lip  to  prevent 
contracture.  Flaps  destined  to  reconstruct  the  lip  may  be  sutured 
directly  to  the  opposite  lip,  and  later  be  used  for  the  desired  purpose. 

Numerous  objections  have  been  raised  to  the  method — difficultv  in 
talking,  in  expectorating,  in  feeding,  and  in  keeping  the  mouth  clean — 
have  been  used  as  arguments  against  it.  But  all  of  these  inconveniences 
have  been  easily  overcome,  and  experience  has  shown  that  the  patients 
are  quite  happy  and  comfortable. 

The  fixation  prevents  contracture  during  the  healing,  and  this  is 
le  main  object  of  the  procedure.  It  allows  operations  to  be  completed 
iccessfully  which  would  otherwise  only  partly  accomplish  their  pur- 
pose. The  use  of  skin  grafts  in  this  region  is  much  facilitated.  It 
introduces  a  method  of  precision  in  operations  on  and  around  the 
lips  which  cannot  be  obtained  otherw^ise.  It  has  been  suggested  to  me 
that  complete  closure  of  the  lips  would  be  advantageous  in  certain 
conditions,  but  I  do  not  feel  that  this  should  be  considered  under  any 
circumstances. 

Jacobson  splints  the  lip,  after  it  has  been  loosened,  by  means  of  a 
rigid  silver  probe  sharpened  at  one  end.  He  inserts  the  probe  through 
the  cheek  about  0.625  cm.  {}-'i  inch)  above  and  outside  of  the  angle  of 
the  mouth  (any  desired  position  may  be  chosen)  and  passes  it  submu- 
cously  along  the  lower  lip  piercing  the  other  cheek  at  a  corresponding 
point.  The  probe  is  then  passed  through  a  small  gauze  pad  on  each 
side;  a  perforated  shot  is  placed  outside  the  gauze,  and  the  excess  of  the 


562  PLASTIC    SURGERY 

probe  is  cut  away.  If  the  probe  is  not  inserted  too  close  to  the  mucous 
surface  and  there  is  no  sloughing,  then  it  may  be  allowed  to  remain  in 
position  for  some  time.  I  have  found  that  there  is  less  danger  of  infec- 
tion at  the  points  where  the  probe  extends  through  the  skin  if  the  edges 
are  sealed  with  collodion  or  with  evaporated  compound  tincture  of 
benzoin.  I  would  also  suggest  that  a  puncture  wound  with  a  narrow 
knife  is  ad\dsable  at  the  point  of  insertion,  instead  of  driving  the  probe 
through  the  skin. 

BIBLIOGRAPHY 

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Alquie.     "Bull,  de  la  Soc.  de  chir."     Paris,  1855,  137. 

Anger,  B.     In  Saint-Martin:  "These  de  Paris,"  1877,  58. 

Auv^ert.     In  Szymanowski:  "Handbuch  der  Operativen  Chirurgie,"  1870,  257. 

Baldwin,  J.  F.     "Surg.,  Gyne.  &  Obst.,"  May,  191 1,  492. 

Beau.     In  Thomas:  "These  de  Montpellier,"  1870,  53. 

Behrexd.     In  Sz}Tnanowski:  "Handbuch  der  Operativen  Chirurgie,"  1870,  281. 

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Berger,  p.     "Congres  francais  de  chirurgie."     Lyon.,   1894.     "Comptes  rendus,"  pp. 

448,  450,  451,  461. 
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473- 
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Buchanan-Syme.     In    Szymanowski:     "Handbuch    der    Operativen    Chirurgie,"    1870, 

257- 
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Chopart,  F.     In  Roux:  "La  Clinique  des  hopitaux  et  de  la  ville,"  1827-1828,  204. 

"Jour,  de  Fourcroy,  iii,  28,  d'apres  le  Compendium  de  chir.  pratique,"  1852-1861, 
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In  Rigaud:  "De  L'Anaplastie,  These  de  Concours,"  1841,  83. 
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In  Nelaton  &  Ombredanne:  "Les  Autoplasties,"  1907,  92. 
Estlander,  J.  A.     "Rev.  m^aw..  de  med.  et  de  chir.,"  1877,  344. 


SURGERY    OF    THE    LIPS  563 

Grant,  \V.  W.     "Jour.  Amer.  Med.  Assn.,"  Sept.  30,  1905,  962. 

"Jour.  Amer.  Med.  Assn.,"  April  29,  1916,  1368. 
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Jacobson,  J.  H.     "Jour.  Amer.  IMed.  Assn.,"  March  2,  1907,  795. 
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564  PLASTIC    SURGERY 

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CHAPTER  XXII 
SURGERY  OF  THE  CHEEK  (MELOPLASTY) 


Some  very  interesting  problems  are  presented  by  cheek  defects  fol- 
lowing injury,  operation  or  disease. 

Superficial  defects  in  the  cheeks  may  be  caused  by  the  excision  of 
tumors,  by  ulceration,  or  by  injury.  Destruction  of  the  whole  thick- 
ness of  the  cheek  may  be  due  to  injury  (especially  war  wounds)  to  the 
removal  of  tumors,  to  disease  (syphiHs,  tuberculosis,  noma.  etc.). 

Loss  OF  SUBSTANCE  OF  THE  CHEEK 
MAY  BE  CLASSIFIED  AS  FOLLOWS:    (l)  117/^;/ 

the  defect  is  in  the  skin  only,  the  treatment 
may  be  (a)  by  skin  grafting  (Ollier- 
Thiersch;  or  whole- thickness  grafts);  {b) 
by  sliding  flaps;  (c)  by  flaps  from  neigh- 
boring skin  (Indian  method). 

(2)  Where  the  main  portion  of  the  defect 
is  in  the  skin,  but  in  addition  there  is  a  small 
opening  into  the  buccal  cavity,  unthout  con- 
tracture of  the  jaw. — This  may  be  treated 
(a)  by  freshening  the  edges  and  drawing 
the  wound  together  with  sutures  if  the 
defect  is  small;  (b)  by  sliding  flaps;  (c) 
with  flaps  from  adjacent  tissue  (Indian 
method) ;  (d)  with  flaps  from  a  distant 
part  (Italian  method). 

(3)  Where  there  is  an  extensive  defect  in- 
volving the  entire  thickness  of  the  cheek,  it 
must  be  filled  with  flaps  having  epithelium 
on  both  sides;  from  the  neck  covered  by  a  cheek  flap;  from  the  cheek 
covered  by  a  neck  or  scalp  flap;  from  the  neck  covered  by  a  flap  from 
the  arm;  from  the  arm.  neck,  or  chest,  by  folding  a  flap  on  itself;  from 
the  arm.  neck,  or  chest,  after  grafting  the  under  surface  of  the  flap  be- 
fore transplantation.     Various  other  combinations  may  be  used. 

Extensive  defects  may  be  divided  into  two  general  groups:  (i) 
Those  in  w^hich  restoration  is  feasible  immediately  after  the  destruc- 

565 


Fig.  660. — Fatal  burn  of  the 
cheek. — A  third  degree  burn  of 
this  size  would  not  ordinarily  be 
fatal.  Marked  to.xic  symptoms 
occurred.  The  situation  and 
depth  of  the  burn  contraindicated 
complete  excision,  which  could 
have  been  done  on  almost  any 
other  part  of  the  body. 


566 


PLASTIC    SURGERY 


tive  operation  or  injury.  (2)  Those  due  to  ulceration  of  some  soft  part, 
or  extensive  destruction,  in  which  the  restoration  must  necessarily  be 
delayed  until  healing  is  complete.  With  this  group  there  is  nearly 
always  associated  contracture  of  the  jaws  due  to  dense  scar  which  may 
involve  the  surrounding  skin,  muscle  and  mucous  membrane — a  con- 
tracture which  is  very  difhcult  to  overcome.  In  long-standing  cases 
atrophy  of  the  mandible  is  also  usually  found. 

If  the  gap  is  small,  and  there  is  plenty  of  normal  skin,  but  the  jaws 
are  locked,  the  cheek  must  be  lined  according  to  the  method  selected. 
If  the  gap  is  large,  the  surrounding  skin  scant,  and  the  jaws  are  locked, 
in  addition  to  the  problem  of  unlocking  the  jaws  we  are  compelled  to 
secure  the  skin  from  a  distance  for  filling  the  gap  in  the  mucous  mem- 


FiG.  661.  Fig.  662. 

Pig.  661. — Operation  for  closing  a  cheek  defect  by  the  French  method  (Serve). — The 
area  ABCD  is  removed,  and  then  the  flap  X  from  the  adjacent  tissues  is  undercut  and 
shifted  upward  to  fill  the  defect.      The  edges  are  carefully  sutured. 

Fig.  662. — Operation  for  closing  a  cheek  defect  by  the  French  method  (modified  from 
Nelalon  and  Ombredanne). — The  dark  lines  indicate  the  incisions.  The  flap  outlined  is 
undercut  and  shifted  in  to  close  the  defect. 

brane,  and  also  in  the  skin.  In  all  complete  cheek  or  lip  defects,  an 
inner  as  well  as  an  outer  lining  has  to  be  provided  in  order  to  prevent 
subsequent  contracture. 


SUPERFICIAL  WOUNDS  OF  THE  CHEEK 


The  Use  of  Skin  Grafts. — In  closing  a  superficial  wound  of  the  cheek, 
which  is  too  large  to  be  sutured,  if  possible  a  single  graft  should  be  used. 
The  graft  may  be  of  the  Ollier-Thiersch  variety,  or  of  whole-thickness, 
obtained  from  some  region  of  the  body  in  which  the  skin  resembles  the 
cheek  as  closely  as  possible  in  thickness  and  texture.  I  have  had  some 
very  satisfactory  results  with  whole-thickness  grafts  on  the  face,  and 
prefer  them  to  the  Ollier-Thiersch  grafts  in  this  situation. 


k 


SURGERY    OF    THE    CHEEK 


;67 


The  French  mclhod   of   closing  cheek  defects  by  sliding  has  been 

extensively  used  by  Morestin,  after  excising  the  scar,  in  old  war  wounds. 

i  The  operation  of  Serre,  as  shown  in  the  diagram,  indicates  the  need  of 


Fig.  663. — -Operation  for  closing  a  cheek  defect  by  the  Indian  method  (modified  from 
Nelaton  and  Ombredanne). —  i.  The  dark  lines  indicate  the  incisions.  2.  The  flap  shifted 
into  the  defect  and  sutured. 


Pig.  664. — Method  of  closing  a  cheek  defect  with  a  flap  from  the  neck  after  extensive 
mobilization  of  skin  of  the  neck  (Moreslin). — i.  The  dotted  area  on  the  cheek  indicates 
the  defect.  The  dark  line  on  the  neck  shows  the  outline  of  the  flap.  The  dotted  line 
indicates  the  lower  limit  of  the  area  to  be  undercut  and  mobilized.  2.  Shows  the  flap 
raised  and  the  method  of  undermining  the  skin  with  scissors. 

making  very  long  incisions,  and  carrying  out  extensive  undercutting 
in  order  to  fill  the  gap.  This  may  cause  a  good  deal  of  asymmetry  of  the 
face,  and  in  manv  instances  is  inadvisable. 


568  PLASTIC    SURGERY 

Xelaton  and  Ombredanne  in  their  work  have  limited  the  use  of  the 
French  method  to  the  restoration  of  small  defects  situated  immediately 
below  the  lower  lid,  but  my  experience  has  been  that  much  wider  use 
can  be  made  of  sliding  flaps. 

In  using  sliding  flaps  in  the  repair  of  a  cheek  defect  care  must  be 
taken  not  to  pull  down  the  lower  eyelid,  or  to  distort  the  angle  of  the 
mouth.  In  other  words,  the  operation  must  be  planned  in  such  a  way 
as  to  avoid  producing  a  new  deformity  while  correcting  an  old  one. 
Pendunculated  flaps  from  adjacent  skin  are  of  great  value  in  certain 
cases,  and  this  method  should  always  be  given  consideration  when  skin 
grafting  is  contraindicated. 

METHODS  OF  REPAIRING  DEFECTS  IN  THE  MUCOSA 

The  mucous  membrane  lining  the  cheek  may  be  destroyed  by  oper- 
ation, injury  or  disease,  and  in  these  cases  the  loss  of  tissue  must  be 
replaced  in  order  to  avoid  contracture.  Gaps  left  by  operation  should 
be  filled  at  once. 

Repair  with]  Pedunculated  Flaps  of  Mucous  Membrane. — If  the 
destruction  is  not  too  large,  it  can  be  repaired  with  pedunculated  flaps 
of  mucosa  from  the  upper  or  lower  lip;  even  the  mucosa  from  the  hard 
palate  has  been  utilized. 

Repair  with  Buried  Grafts. — The  cheek  or  adherent  lip  may  be 
lined  with  epithelium  b}^  using  a  buried  Ollier-Thiersch  graft  applied 
according  to  Esser's  method.  He  prepares  a  cavity  of  the  desired 
size  and  makes  a  cast  of  it  with  dental  impression  material.  This 
cast,  after  being  covered  with  a  single  Ollier-Thiersch  graft  (raw  sur- 
face outside),  is  inserted  into  the  cavity  and  the  skin  closed.  Three 
weeks  later  the  cavity  is  opened  and  the  cast  is  removed,  leaving  the 
space  covered  with  epithelium.  The  procedure  is  very  useful  at  times, 
but  the  results  cannot  be  compared  with  those  following  the  use  of 
pedunculated  flaps  of  whole-thickness  skin. 

Repair  with  Pedunculated  Flaps  of  Skin.^ — Binnie  describes  an  oper- 
ation, probably  based  on  Rotter's  idea,  for  lining  a  cheek  defect.  If  the 
defect  is  in  the  mucous  membrane  alone,  a  flap  of  suitable  size  and 
shape  is  raised  from  the  neck  with  the  pedicle  above,  and  is  inserted 
fskin  side  inward)  in  an  incision  through  the  cheek  just  in  front  of  the 
masseter  muscle.  The  neck  defect  is  sutured  or  grafted.  Ten  days 
later  the  pedicle  is  cut,  the  end  of  the  flap  is  sutured  into  the  posterior 
portion  of  the  defect  in  the  mucosa,  and  the  incision  through  the  cheek 


SURGERY    OF    THE    CHEEK 


;69 


is  closed.  If  it  has  been  necessary  in  removing  a  growth  to  split  the 
cheek,  the  neck  flap  may  be  sutured  into  the  defect  in  the  mucosa 
and  the  cheek  closed  over  it,  the  rest  of  the  procedure  being  the  same 
as  just  described  (Fig.  665). 

Many  operators  line  cheek  defects  by  turning  in  the  surrounding 
skin,  and  then  covering  it  with  a  pedunculated  flap  from  the  neck. 
In  my  hands  this  has  proved  very  useful  in  small  defects  through  the 
full  thickness  of  the  cheek,  in  the  absence  of  contracture  of  the  jaws. 
(Fig.  666). 

The  use  of  hairy  skin  turned  into  the  mouth  has  always  been  con- 
traindicated,  as  the  hair  continues  to  grow,  but  this  objection  may  be 


Fig.  665. —  Method  of  lining  a  cheek  after  destruction  of  mucous  membrane  (Binnie). — - 
I.  The  flap  DEF  from  the  neck  is  inserted  in  an  incision  through  the  check  in  front  of  the 
masseter,  and  is  sutured  into  the  defect  in  the  mucous  membrane  ABC.  Ten  days  later 
the  pedicle  is  cut  and  all  defects  are  sutured  or  grafted.  2.  If  the  growth  cannot  be  re- 
moved from  the  inside,  the  incision  AB  is  made  through  the  cheek.  3.  The  neck  flap  is 
inserted.  The  cheek  flaps  are  closed  over  it,  and  then  the  same  procedure  is  continued 
as  in  I . 


overcome  by  the  use  of  .v-ray  or  radium  treatment  of  the  flap  before 
it  is  turned  in.  Cole  has  tested  this  procedure  frequently  in  war 
wounds  and  finds  that  he  can  advantageously  utilize  flaps  which 
without  depilation  would  have  been  contraindicated.  Hairless  skin 
however,  is  to  be  preferred  whenever  it  can  be  obtained  (Fig.  667,  668, 
669). 

On  several  occasions  I  have  turned  up  a  flap  from  the  neck  with 
its  base  below  the  ramus  of  the  jaw,  and  after  passing  it  through  an 
incision  between  the  mandible  and  soft  parts  have  sutured  it  into  the 
defect  in  the  mucous  membrane.  Two  weeks  later  the  pedicle  was 
cut.     The  results  were  satisfactorv. 


57° 


PLASTIC    SURGERY 


Pig.  666. — Method  of  closing  a  cheek  defect  (Voeckler). — i.  The  solid  black  line  in- 
dicates the  incision  around  the  defect  and  outlining  the  flap  from  the  neck.  As  much  of 
the  tissue  as  necessary  from  the  margins  of  the  defect  is  turned  in  and  is  used  to  line  the 
cheek.      The  flap  from  the  neck  covers  the  raw  surface  as  indicated  in  2  and  3. 


'''''  ^'yjy'i!l. 


Pig.  667. — Operation  for  closing  a  cheek  defect  {Cole). — i.  The  dotted  line  indicates 
the  incision  through  an  area  from  which  the  hair  has  been  removed  by  radiation.  2.  The 
flap  with  the  pedicle  at  the  margin  of  the  defect  is  turned  in  to  line  the  cheek  by  means  of 
the  special  suture  shown|[^in  3. 


Fig.   668. — Cole's  operation  for  closing  a  cheek  defect,  conlinued — i.   A  pedunculated  flap 
from  the  neck  is  shifted  up  to  cover  the  raw  surface.      2.   The  neck  wound  closed. 


SURGERY    OF    THE    CHEEK 


57i 


Gersuny's  Operation  (1887). — An  incision  is  made  from  the  corner 
of  the  mouth  down  to  the  border  of  the  lower  jaw,  and  backward  to 
the  anterior  edge  of  the  masseter.     The  flap  thus  outlined  is  raised, 


Fig.  669. — Operation  for  closing  a  cheek  defect  (Cole). —  i.  The  defect  in  the  mucous 
membrane  of  the  mouth  closed  by  skin  obtained  from  the  neighborhood,  the  pedicles  being 
on  the  margin.  The  shaded  area  B  indicates  a  raw  surface.  The  dotted  lines  indicate  the 
outlines  of  the  pedunculated  flap  A  from  the  neck.  2.  The  flap  A  shifted  over  to  cover  the 
raw  area  and  a  portion  of  the  wound  closed.  The  dotted  line  indicates  the  point  of 
division.      The  pedicle  is  then  used  to  fill  in  the  defect  on  the  neck. 


Fig.  670. — Method  of  lining  the  cheek  (Gersuny). —  r.  The  incision  ABC  is  made 
through  the  full  thickness  of  the  cheek,  and  the  flap  is  turned  up.  The  incisions  DF  and 
FE  are  made  which  outline  a  flap  large  enough  to  line  the  cheek.  2.  The  flap  is  folded 
up  until  the  skin  side  is  inward,  and  is  sutured  into  the  defect  in  the  mucous  membrane. 
The  pedicle  is  composed  of  the  subcutaneous  tissues.  Then  the  cheek  flap  is  lowered  and 
sutured  into  position  over  it 

the  growth  is  removed,  or  scar  tissue  is  divided,  and  the  flap  is  held 
upward.  The  under  surface  of  this  flap,  from  which  mucous  mem- 
brane is  lacking,  is  covered  with  a  flap  from  the  skin  of  the  neck, 
the  pedicle  of  which  consists  entirely  of  the  underlying  soft  parts  and 


572 


PLASTIC    SURGERY 


periosteum  along  the  mandible.  The  connection  with  the  surround- 
ing skin  is  completely  severed,  the  flap  is  turned  up,  skin  surface  toward 
the  mouth,  and  is  sutured  to  the  edges  of  the  gap  in  the  mucous 
membrane.  The  cheek  flap  is  then  turned  down  and  sutured  over 
this.  This  method  is  valuable  in  certain  instances,  one  advantage 
being  that  the  entire  operation  can  be  completed  at  one  sitting.  The 
disadvantage  is  that  the  circulation  through  the  pedicle  will  not  always 
be  sufficient  to  nourish  the  flap  (Fig.  670). 


METHODS  OF  REPAIRING  DEFECTS  INVOLVING  THE 
FULL  THICKNESS  OF  THE  CHEEK 

Many  operations  have   been   devised   for   the   repair   of   defects 
involving  the  full  thickness  of  the  cheek,  but  only  a  few  of  the  best 


Pig.  671. — Method  of  closing  a  cheek  defect,  i.  The  dark  lines  indicate  the  flaps 
which  are  made  through  the  full  thickness  of  the  cheek.  2.  The  flaps  are  approximated 
and  sutured,  and  the  soft  parts  above  and  below  are  drawn  together  to  fill  the  gaps. 


will  be  described  here.     In  any  one,  some  modifications  in  detail  may 
be  advisable  to  meet  conditions  peculiar  to  the  individual  case. 

Kraske's  Operation. — A  flap  of  sufficient  size  to  fill  the  gap  is 
turned  up  from  immediately  below  and  is  sutured  into  it.  The  pedicle 
through  which  nutrition  is  preserved  for  greater  safety  should  include 
a  portion  of  the  skin,  but  may  be  entirely  of  subcutaneous  tissue.  If 
the  bridge  of  skin  is  left,  the  pedicle  is  cut  through  after  three  weeks. 
By  this  method  a  raw  area  twice  the  size  of  the  defect  is  left,  which 
may  be  filled  by  sliding  flaps,  or  by  grafts,  according  to  the  nature  of 
the  case  (Fig.  672). 


SURGERY    OF    THE    CHEEK 


573 


Another  method  of  closing  a  cheek  defect  may  be  illustrated  by 
the  following:  A  patient  came  under  my  care  with  a  cheek  lesion  of 
three  years'  standing,  following  excision  of  the  superior  maxilla  with 


Fig.  672. — Operation  for  the  repair  of  a  cheek  defect  {Kraske). — i.  The  growth  is 
excised.  The  flap  A  of  sufficient  size  to  fill  the  defect  is  raised  from  below,  with  its  pedicle 
on,  or  close  to  the  margin  of  the  defect.  2.  The  fiap  sutured  into  the  defect.  The  raw 
surfaces  are  grafted  or  covered  with  a  flap  from  the  neck. 

overlying  soft  parts  for  sarcoma  of  the  antrum.  The  condition  is 
well  shown  in  the  accompanying  figures.  There  was  paralysis  of  the 
right  corner  of  the  mouth.  The  defect  extended  from  the  outer  angle 
of  the  right  eve  to  the  nose,  and  well  down  on  to  the  cheek.     The  eve 


Fig.  673. — Cheek  defect  following  e.xcision  of  a  sarcoma  of  the  antrum  three  years 
previously, — i  and  2.  Lateral  and  front  views  of  the  defect.  3.  The  defect  was  closed  by 
means  of  a  flap  of  tissue  from  the  cheek  below,  the  pedicle  being  at  the  lower  rim  of  the 
opening.  This  flap  was  turned  upward,  skin  side  inward,  and  its  edges  were  sutured  under 
the  loosened  edges  from  around  the  margin  of  the  opening.  The  raw  surface  was  then 
grafted  with  Ollier-Thiersch  grafts.      The  photograph  was  taken  two  weeks  after  operation, 

was  sagging,  and  was  held  by  the  soft  parts  only,  the  floor  of  the  orbit 
having  been  removed.  The  lower  lid  was  intact,  the  lachrymal  sac 
was  destroyed,  the  septum  was  missing;  through  the  opening  could  be 
seen  the  nasal  surface  of  the  hard  nalate.  and  the  action  of  the  soft 


574 


PLASTIC    SURGERY 


palate  in  swallowing  and  speaking.  In  other  words,  this  defect 
opened  into  the  nasal  and  pharyngeal  cavities  and  not  into  the  mouth. 
The  cheek  just  below  the  defect  was  quite  thick,  and  covered  with 
hairless  skin  which  was  not  infiltrated  with  scar  (Figs.  673  and  674). 
Operation. — An  incision  extending  from  the  nose  to  the  outer 
angle  of  the  eye  was  made  along  the  lower  outer  border  of  the  thick- 
ened cheek  area,  and  a  hinged  flap  of  skin  and  fat  f^which  filled  the 
opening  without  difficulty;  was  raised  with  its  pedicle  near  the  inner  rim 
of  the  defect.  The  soft  parts  were  then  loosened  all  around  the  other 
portion  of  the  margin,  and  the  edges  of  the  hinged  flap,  with  its  skin 
surface  inward,  was  sutured  with  mattress  sutures,  high  up  under  the 
marginal  flap,  thus  bringing  raw  surface  to  raw  surface.  The  edges 
of  the  marginal  flap  extended  over  the  raw  surface  of  the  hinged  flap 
to  some  extent,  and  partly  covered  it.     The  remaining  raw  surface 


Fig.   674. — Cheek   defect,    continued. — i.    Taken    two   weeks    after  operation, 
eighteen  months  after  operation. 


2.   Taken 


was  immediately  covered  with  an  Ollier-Thiersch  graft.  There  was 
no  infection,  and  primary  healing  occurred.  The  patient  was  dis- 
charged two  w^eeks  after  operation,  much  improved.  In  this  method 
we  made  use  of  a  thick  hinged  flap  from  below  the  defect,  the  raw 
surface  of  which  was  partially  covered  by  the  marginal  flap  from 
above.     The  remainder  of  the  defect  was  grafted. 

Cheyne  and  Burghard's  Operation  for  a  Small  Gap  in  the  Cheek, 
without  Contracture  of  the  Jaws.  —  The  edges  are  freshened,  and  all 
scar  is  excised.  A  flap  (of  skin  and  subcutaneous  tissue)  from  over 
the  masseter  muscle,  with  its  pedicle  behind  and  near  the  defect,  is 
raised,  turned  over  so  that  skin  surface  is  inward,  and  sutured  to  the 
edges  of  the  mucous  membrane.  After  healing  is  complete  (two  to 
three  weeks)  the  pedicle  is  divided  and  sutured  into  the  posterior 
portion  of  the  defect,  flap  is  then  raised  from  the  skin  over  the  jaw 
and  is  shifted  upward  to  cover  the  raw  surface  of  the  first  flap.     Second- 


SURGERY    OF    THE    CHEEK 


575 


ary  shaping  operations  are  necessary  to  form  the  angle  of  the  mouth, 
etc.  (Fig.  675). 

Shrady's  Operation.—  The  cheek  defect  is  closed  by  the  douljJe 
transfer  of  a  flap  from  the  lower  portion  of  one  arm  above  the  elbow, 
which  is  implanted  into  an  incision  on  the  radial  side  of  the  forefinger 
of  the  other  hand.  In  due  time  the  flap  is  cut  away  from  the  arm 
and  transferred  on  the  finger  to  line  the  cheek.  The  flap  is  subse- 
quently cut  away  from  the  finger,  and  the  raw  surface  covered  with 
sliding  flaps  from  the  neighboring  parts. 


mz}i 


Fig.  675. — Operation  for  closing  a  cheek  defect  {Cheyne  i-  Burghard). —  i.  The  dark 
lines  indicate  the  incision  for  raising  a  hinged  flap.  2.  The  hinged  flap  raised,  turned  for- 
ward, sutured  into  the  defect,  skin  side  inward.  The  dotted  line  AA  indicates  the  incision 
to  divide  the  pedicle.  3.  Two  weeks  later  the  pedicle  is  cut  and  the  end  of  the  flap  is 
sutured  into  the  defect.  The  dark  line  indicates  the  flap  which  is  to  be  shifted  up  from 
the  chin  to  cover  the  raw  surface  of  the  hinged  flap.      All  other  defects  are  sutured  or  grafted. 

Czemy's  Operation. — A  flap  is  raised  from  the  neck  with  its  pedicle 
between  the  ear  and  the  zygoma,  and  adjacent  to  the  defect.  It 
should  be  long  enough  to  reach  the  most  distant  portion  of  the  open- 
ing after  the  free  end  has  been  folded  back  on  the  body  of  the  flap, 
so  that  epithelium  covers  on  both  sides.  If  the  flap  is  shifted  at  once 
after  folding  and  suturing  raw  surface  to  raw  surface,  it  is  united  only 
to  the  sides  of  the  cheek  defect,  the  reflected  edge  and  the  base  being 
subsequently  sutured  into  position.  If  healing  of  the  folded  portion 
is  allowed  to  take  place  first  (which  is  preferable),  the  reflected  edge 
is  divided,  and  all  but  the  pedicle  portion  is  sutured  into  the  defect. 
This  is  done  subsequently,  and  several  secondary  operations  may  be 
necessary  (Fig.  676). 


576 


PLASTIC    SURGERY 


Israel's  Operation.  First  Stage  . — A  pedunculated  flap  of  skin  and 
subcutaneous  tissue  is  raised  from  the  skin  of  the  neck.  The  pedicle 
is  just  below  the  angle  of  the  jaw  and  is  oblique  in  direction.     The 


Pig.  676. — Czerny's  operation  for  closing  a  cheek  defect  {J.  S.  Stone). — i.  Outline 
of  the  flap.  Note  the  position  of  the  pedicle.  The  dotted  line  across  the  flap  indicates 
the  point  at  which  the  extremity  is  folded  on  itself.  2.  The  flap  in  position,  and  the  neck 
wound  closed. 


12  3 

Fig.  677. — Israel's  operation  for  closing  a  cheek  defect  (J.  5.  Stone). — i.  The  dark 
line  outlines  the  flap  which  is  to  close  the  cheek  defect.  2.  Flap  raised,  turned  over,  and 
sutured  skin  surface  inside  to  mucous  membrane  of  the  cheek.  The  neck  defect  closed. 
3.  The  pedicle  is  severed  and  the  flap  is  folded  forward  on  itself  and  sutured.  The  posterior 
border  of  the  double-faced  flap  is  subsequently  split  and  the  margins  sutured  into  the  defect, 
thus  completely  closing  it. 

flap  should  be  long  enough  when  raised  to  reach  the  most  distant  point 
in  the  defect  without  tension,  and  wide  enough  to  fill  the  gap.  It 
must  be  remembered  that  flaps  from  the  neck  contract  a  great  deal 


SURGERY    OF    THE    CHEEK 


577 


and  allowance  must  be  made  fur  this  shrinkage.  After  being  raised, 
the  flap  is  turned  over,  skin  surface  inside,  and  its  free  end  is  carefully 
sutured  to  the  loosened  mucous  membrane  at  the  margins  of  the 
defect,  except  in  the  portion  under  the  pedicle  (Fig.  677). 

It  can  be  seen  from  this  that  the  pedicle  bridges  over  an  area  of 
normal  skin,  and  the  skin  surfaces  should  be  kept  apart  with  gauze. 
The  neck  wound  is  closed,  as  far  as  may  be,  with  sutures. 

Second  Stage. — Three  weeks  later  the  pedicle  is  cut.  The  exposed 
raw  surfaces  having  been  freshened  the  posterior  portion  of  the  flap  is 
turned  forward  and  sutured,   thus  covering   the  raw  surface  of  the 


Fig.  678. — Method  of  closing  cheek  defect  with  flap  from  the  neck  {Blair). — i.  Flap 
raised  from  the  neck  and  folded  on  itself.  2.  After  healing  is  complete  the  flap  is  shifted 
into  the  cheek  defect  and  its  sides  sutured  to  the  freshened  edges.  2.  Two  to  three  weeks 
later  the  pedicle  is  cut,  the  upper  end  of  the  flap  is  opened  and  both  extremities  of  the  flap 
are  fitted  into  the  defect.      Note  the  relaxation  incision  on  the  neck. 


portion  previously  implanted.  This  leaves  a  sinus  opening  into  the 
mouth  at  the  posterior  edge. 

Third  Stage. — Two  or  three  weeks  later  the  flap  is  opened  at  its 
point  of  reflexion  (posterior  margin)  and,  after  preparation  of  the  edge  of 
the  defect,  the  inner  layer  of  the  flap  is  sutured  to  mucous  membrane 
and  the  outer  to  the  skin.  Several  secondary  shaping  operations  may 
be  necessary. 

Hahn's  Operation. — This  operation  difl'ers  from  that  of  Israel  only 
in  that  the  flap  is  obtained  from  the  skin  of  the  chest  (down  to  the 
nipple)  with  its  base  at  the  clavicle.  Tht  head  must  be  flexed  and 
immobilized. 


37 


578 


PLASTIC    SURGERY 


Pig.  679. — Operation  for  closing  a  cheek  defect  with  flap  from  the  shoulder  (v. 
Hacker). — The  flap  from  the  shoulder  is  raised  and  sutured  into  the  cheek  defect,  skin 
surface  inward.  The  wound  on  the  shoulder  is  partially  closed  by  sutures.  Two  or  three 
weeks  later  the  pedicle  is  cut  and  may  be  used  to  cover  the  raw  surface,  or  this  area  mg,y  be 
grafted. 


I  2 

Fig.  680. — Restoration  of  cheek  and  angle  of  mouth  (v.  Hacker). — i.  The  scar  is 
divided  from  the  angle  of  the  mouth  to  the  masseter,  and  the  skin  over  the  masseter  is 
undermined.  The  flap  A  from  the  neck  is  raised,  passed  under  flap  B,  and  after  being 
notched  is  sutured  into  the  defect  to  form  angle  of  mouth,  skin  side  inward.  The  neck  I 
wound  is  closed.  2.  Two  or  three  weeks  later  the  lower  attachment  of  the  flap  B  is  divided 
and  split. 


SURGERY   OF   THE   CHEEK 


579 


Von  Hacker's  Operations. — A  number  of  methods  of  closing  cheek 
defects  have  been  suggested  by  von  Hacker.  He  has  used  a  peduncu- 
lated flap   from    the    clavicular  region  (with  its  pedicle    toward    the 


Fig.  68 1. — v.  Hacker's  operation  for  the  restoration  of  cheek  and  angle  of  mouth,  con- 
tinued.— I.  The  flap  A  is  divided  across  the  posterior  margin  of  the  defect,  and  is  sutured 
into  place.  The  flap  B  is  shifted  to  cover  the  raw  surface  and  complete  the  angle  of  the 
mouth.     2.   The  pedicle  A'  is  used  to  fill  in  the  remaining  raw  surface. 

midline),  which  is  raised  and  sutured  into  the  defect,  skin  surface  inside. 
After  two  or  three  weeks  the  pedicle  is  cut  and  the  raw  surface  may  be 
closed  by  reflecting  the  pedicle  end,  or  by  grafting. 


Fig.  682. — Operation  to  close  a  cheek  defect  (v.  Hacker). — i.  The  flap  A  fromtthe 
hairless  portion  of  the  neck  is  raised  and  inserted  under  the  undermined  skin  B  over 
the  masseter,  and  is  sutured  into  the  cheek  defect,  skin  surface  inward.  The  wound  on 
the  neck  is  closed.  2.  After  two  or  three  weeks  the  flap  B  is  raised  as  shown.  The  flap 
A  is  divided  at  the  line  C  and  is  sutured  into  the  defect,  thus  completely  closing  it. 

Another  method,  also  by  von  Hacker,  is  shown  in  the  diagrams. 
A  flap  from  the  neck  is  raised,  turned  skin  surface  inward  and  passed 
under  a  bridge  of  normal  skin,  which  lies  between  the  pedicle  and  the 


58o 


PLASTIC    SURGERY 


opening.  The  free  end  of  the  flap  is  sutured  into  the  defect.  In  due 
time  one  end  of  the  bridge  of  normal  skin  is  cut,  the  pedicle  of  the  flap 
is  also  cut,  and  the  defect  is  completely  closed.  Then  the  pedicle  end 
of  the  flap,  and  the  bridge  of  the  skin  are  utilized  to  cover  the  raw 


Fig.  683. — V.  Hacker's  operation  to  close  a  cheek  defect,  continued. — i.   Flaps  B  and  A'  are 
then  mobilized  and  shifted  forward  to  cover  the  raw  surface  A.     2.  The  flaps  sutured. 

surface  of  the  implanted  flap.  The  neck  wound  is  sutured  immediately 
after  the  flap  has  been  raised.  Several  secondary  operations  are  neces- 
sary to  complete  the  work  (Figs.  679-684). 


Fig.  684. — Operation  to  close  a  cheek  defect  {v.  Hacker). — i.  After  the  relief  of  the 
contracture  the  flap  A  is  raised  from  the  neck  and  is  sutured  into  the  defect,  skin  side 
inward.  The  flap  B  may  be  shifted  at  once,  or  later,  to  cover  the  raw  surface  A.  2.  Two 
or  three  weeks  later  the  pedicle  of  the  flap  A  is  cut  and  fitted  into  the  defect.  3.  The 
defect  completely  closed. 

Horsley's  Operation. — Horsley  lines  the  cheek  defect  with  a  flap 
turned  up  from  the  skin  of  the  neck  which  is  inserted  (skin  side  inward) 
through  an  incision  between  the  mandible  and  overlying  soft  parts, 
and  is  sutured  to  the  edges  of  the  mucous  membrane.  The  raw 
surface  of  the  flap  is  covered  with  a  suitably  shaped  flap  from  the 


SURGERY    OF    THE    CHEEK  58 1 

forehead  which  has  as  its  pedicle  the  anterior  temporal  artery,  which  is 
dissected  out.  When  the  flap  is  shifted,  the  artery  is  implanted  into 
the  soft  parts  in  an  incision  made  to  receive  it.  This  method  is  very 
similar  to  that  used  by  Monks  in  forming  an  eyelid,  described  in  a 
previous  section.  I  can  see  no  advantage  in  the  transplantation  of  such 
a  flap  in  cheek  defects,  as  the  mutilation  and  operative  procedures  are 
much  greater  than  those  belonging  to  simpler  methods.  Moreover, 
with  properly  made  pedunculated  flaps  there  is  little  difliculty  in  preserv- 
ing adequate  circulation. 

Author's  Method.  '^ — A  patient  had  a  severe  attack  of  typhoid  fever 
and  was  in  bed  for  about  ten  w^eeks.  While  he  was  in  a  comatose 
condition  a  small  ulcer  appeared  on  the  inside  of  the  right  cheek,  w^hich 
spread  and  finally  went  through  its  entire  thickness.  When  he  w^as 
admitted  to  the  hospital  I  found  a  hole  with  a  circular,  funnel-shaped 
opening  involving  the  entire  thickness  of  the  right  cheek.  The  external 
diameter  measured  6.25  cm.  (2^^  inches),  the  internal,  3.75  cm.  (i^^^ 
inches).  The  defect  extended  from  the  level  of  the  hard  palate  to  the 
floor  of  the  mouth,  and  from  the  ramus  of  the  jaw  to  within  half  an 
inch  of  the  angle  of  the  mouth.  The  walls  of  the  defect  were  made  up 
of  very  dense  scar  tissue  of  woody  hardness,  which  also  involved  the 
adjacent  soft  parts.  Posteriorly,  a  thick  column  of  scar  tissue  en- 
croached upon  the  oral  cavity,  and  this,  with  a  smaller  band  anteriorly, 
bound  the  jaws  together. 

The  mucosa  of  both  the  upper  and  the  lower  jaw  on  this  side  had 
evidently  been  implicated  in  the  destructive  process,  and  the  alveolar 
processes  were  covered  with  dense  scar  tissue,  which  w-as  continuous 
with  the  walls  of  the  defect.  The  parotid  duct  could  not  be  located. 
All  the  teeth  were  in  bad  condition  on  the  right  side,  only  one  or  two 
incisors  being  left.  The  tongue  on  this  side  was  closely  adherent  to  the 
body  of  the  lowxr  jaw  along  the  floor  of  the  defect  to  such  an  extent 
that  only  the  tip  could  be  moved.  The  patient  was  unable  to  open  his 
mouth  even  \Vith  the  greatest  eft'ort.  This  condition  seemed  to  be  due  to 
the  scar  tissue  and  not  to  any  trouble  with  the  joints,  as  a  certain 
amount  of  lateral  joint  movement  could  be  demonstrated.  Articula- 
tion was  very  indistinct,  and  talking  was  impossible  unless  the  opening 
was  plugged  with  a  dressing.  The  patient  was  obliged  to  force  his 
food  with  his  finger  back  behind  the  teeth  on  the  left  side,  and  was 
unable  to  feed  himself  through  the  defect  as  the  unequal  movements  of 
the  tongue  forced  the  food  back  through  the  opening. 

'  Davis,  J.  S.:  "Anns.  Surg.;"  March,  1913,  361. 


582  PLASTIC    SURGERY 

For  the  repair  of  this  large  defect  I  decided  upon  a  flap  with  a 
broad  pedicle  which  would  fulfil  the  following  conditions:  It  must 
not  contract  appreciably  after  being  implanted;  it  must  have  enough 
thickness  to  fill  the  defect  without  causing  a  depressed  area  after  healing 
was  complete;  and  it  must  be  formed  of  soft  tissue  (preferably  fat,  with 
whole-thickness  skin  on  both  sides)  which  would  conform  in  appearance 
to  the  surrounding  skin  externally,  and  take  the  place  of  the  mucous 
membrane  in  the  mouth.  In  order  to  avoid  any  further  mutilation 
of  the  face  or  neck  I  determined  to  utilize  the  right  arm. 

Operation. — A  large  pedunculated,  rectangular-shaped  flap  7.5 
X  16.  cm.  (3  X  6%  inches),  made  up  of  whole-thickness  skin  with  its 
subcutaneous  fat,  was  raised  from  the  outer  side  of  the  right  arm,  with 
its  base  in  the  mid-deltoid  region.  The  flap  was  folded  on  itself,  and 
the  distal  end  sutured  to  the  pedicle  and  underlying  muscle  with 
interrupted  sutures  placed  at  intervals  in  the  edges,  thus  bringing  raw 
surface  to  raw  surface,  and  forming  a  flap  with  a  double  thickness  of  fat 
within,  and  with  whole-thickness  skin  on  the  front  and  back.  The  flap 
was  then  stretched  by  means  of  four  sutures  on  a  gauze-covered  wire 
frame,  to  keep  it  flat  and  to  control  contraction,  and  a  number  of  small 
stab  wounds  were  made  in  it  to  relieve  congestion.  The  area  from 
which  the  flap  was  raised  was  grafted  immediately  with  Ollier-Thiersch 
grafts. 

Fourteen  days  later  as  much  as  possible  of  the  scar  tissue  was 
removed  from  the  sides  and  upper  portion  of  the  defect.  The  tongue, 
which  was  adherent  almost  to  its  base,  was  freed  and  drawn  to  the 
left  side.  Even  after  the  scar  tissue  bands  had  been  dissected  out, 
the  jaws  could  not  be  opened  to  any  extent,  probably  owing  to  the 
great  infiltration  of  the  muscles  with  scar  tissue. 

The  flap  on  the  arm  was  then  opened  across  its  free  end,  the  edges 
were  freshened,  the  arm  was  raised,  and  the  flap  was  sutured  into  the 
defect  with  catgut  in  the  mouth,  and  silk  on  the  cheek.  In  this  way 
the  upper  two-thirds  of  the  defect  was  filled.  The  arm  was  then  held 
in  position  by  means  of  a  plaster  cast.  The  patient  was  placed  on  a 
Gatch  bed.  Water  by  rectum  was  commenced  by  the  Murphy  method, 
and  continued  for  several  days.  Only  sterile  water  was  given  by 
the  mouth,  and  nasal  feeding  was  continued  until  the  pedicle  of  the 
flap  was  amputated.  Eleven  days  after  implantation  the  cast  was 
removed,  and  the  pedicle  was  cut  through,  close  to  the  arm.  Eleven 
days  later  the  scar  tissue  was  removed  from  the  lower  third  of  the 


SURGERY    OF    THE    CHEEK  583 

defect  and,  after  the  edges  had  been  trimmed  and  freshened,  the  flap 
was  sutured  so  as  to  completely  close  the  remainder  of  the  opening. 
By  this  means  the  defect  was  entirely  closed  with  a  thick  flap  with 
skin  on  both  sides,  which  was  nearly  level  with  the  surrounding  tissues. 
There  was  a  very  marked  improvement  in  the  apjK'arance  of  the 
patient.  The  flap  was  in  excellent  condition,  and  the  skin  was  soft, 
pliable,  and  of  normal  color.  Within  the  mouth  the  skin  was  pale 
and  soft,  and  seemed  to  be  gradually  assuming  the  characteristics  of 
the  mucous  membrane.  The  jaws  could  be  opened  so  that  the  tip 
of  the  finger  could  be  introduced  between  the  incisor  teeth,  and  there 
was  quite  a  little  lateral  motion.     There  was  free  motion  of  the  tongue. 


1234  5 

Fig.  685. — Cheek  defect  following  noma  (typhoid  fever  complication).  Duration 
two  years. — i.  Note  the  depth  of  the  posterior  wall  of  the  defect  and  the  extent  of  the  scar 
tissue  involvement  around  the  opening.  The  tongue  can  be  seen  adherent  to  the  lower 
portion  of  the  defect.  2.  Observe  the  position  of  the  defect  in  regard  to  the  angle  of  the 
mouth.  The  photograph  shows  the  maximum  separation  of  the  jaws.  3  and  4.  Schematic 
drawing  showing  the  method  of  formation  of  the  arm  flap.  3.  The  outline  of  the  flap 
having  its  pedicle  AA  above,  and  its  free  end  at  the  line  BB.  The  flap  after  being  raised 
was  folded  on  itself  on  the  line  CC.  4.  The  free  end  of  the  flap  BB  was  sutured  to  the 
pedicle  and  underlying  muscle  at  AA,  and  the  edges  are  held  together  with  sutures,  thus 
forming  a  flap  with  a  double  thickness  of  fat  \\'ithin,  and  with  whole-thickness  skin  on  both 
sides.  The  area  D  was  immediately  grafted  with  Ollier-Thiersch  grafts.  The  flap  was 
stretched  on  a  wire  frame  and  after  two  weeks  the  free  end  along  the  line  CC  was  split, 
the  sides  w^ere  freshened  and  the  flap  was  implanted  into  the  freshened  edges  of  the  defect. 
5.   The  position  of  the  arm  and  head  in  the  plaster  cast. 

and  the  feeding  process  was  simplified.  Speech  was  much  improved. 
The  circulation  of  the  flap  had  been  assured,  and  most  of  the  shrinkage 
had  taken  place  before  it  was  transplanted.  There  was  no  unsightly 
scarring  of  the  cheek  or  neck,  and  the  area  from  which  the  flap  was 
raised  had  been  entirely  healed  by  means  of  Ollier-Thiersch  grafts 
at  the  time  the  flap  was  ready  for  transplantation. 

The  only  serious  disadvantage  of  the  method  is  the  constrained 
position  of  the  patient  during  the  time  the  circulation  from  the  cheek 
is  entering  the  flap. 

On  the  whole  the  result  was  satisfactorv.     There  was  still  much 


584 


PLASTIC    SURGERY 


limitation  of  the  jaw  movement,  but  this  was  somewhat  improved  by 
subsequent  removal  of  the  condyle  on  that  side.  Furthermore,  and 
most  important,  is  the  fact  that  the  patient  was  relieved  of  a  hideous 
deformity  which  would  have  prevented  his  living  a  comfortable, 
healthy  life,  and  would  probably  have  interfered  with  his  obtaining 
employment  (Figs.  685-686). 

Lauenstein's  Operation. — A  bridge  of  skin  and  subcutaneous  tissue 
is  raised  from  the  midline  over  the  sternum,  the  incisions  being 
vertical.  From  one  side  on  the  same  level  is  raised  a  hinged  flap  with 
pedicle  close  to  the  margin  of  the  bridge  and  of  sufhcient  size  to  cover 
the  under  surface  of  the  bridge  flap.  This  is  turned  over,  drawn 
beneath  the  bridge  flap,  and  held  in  position  by  sutures.     The  defect 


Fig.  686. — Cheek  defect  following  noma,  continued. — i.  The  pedicle  was  cut  from  the 
arm.  eleven  days  later.  The  photograph  shows  the  flap  nine  days  after  cutting  the  pedicle, 
and  before  fitting  it  into  the  lower  portion  of  the  defect.  2  and  3.  Taken  five  years  after 
implanting  the  flap.  Note  the  scar  left  by  the  recent  excision  of  the  condyle.  4.  Extent 
of  jaw  motion  possible  after  the  excision.  The  skin  lining  the  cheek  has  assumed  the  ap- 
pearance and  the  function  of  the  mucous  membrane. 


left  by  the  hinged  flap  is  immediately  grafted.  After  circulation  has 
been  established  the  pedicle  is  cut.  Then  the  lateral  incisions  marking 
out  the  pedicle  of  the  double  faced  flap  are  made,  thus  cutting  off  the 
lateral  circulation.  The  pedicle  is  dissected  up  so  that  the  circula- 
tion of  the  flap  enters  through  the  upper  and  lower  attachments.  Then 
the  lower  attachment  is  gradually  severed,  and  the  circulation  enters 
entirely  through  the  upper  attachment.  It  takes  a  considerable  time 
(39  days  in  Lauenstein's  case)  before  the  flap  is  shifted  to  the  cheek 
defect.     Two  weeks  later  the  pedicle  is  cut  and  sutured  (Fig.  687). 

This  type  of  operation  is  a  very  valuable  one.  The  gradual  separa- 
tion of  the  flap  from  its  attachments  assures  the  adjustment  of  circu- 
lation, so  that  by  this  seemingly  slow  process  much  time  can  be  saved, 
and  there  will  be  no  sloughing  after  the  flap  has  been  shifted. 

Lerda  has  used  a  rather  heroic  method  of  closing  a  large  check 


SURGERY    OF    THE    CHEEK 


585 


defect.  He  shifts  the  entire  mouth  toward  the  gap  by  means  of 
horizontal  incisions  continuous  with  the  upper  and  lower  borders  of 
the  defect.     These  incisions  extend  through  the  full  thickness  of  the 


Fig.  687. — Operation  for  closing  a  cheek  defect  (Lauenslein,  Annals  of  Surgery,  1893, 
57). —  I.  A  indicates  the  bridge  flap  which  is  undermined;  B,  the  hinged  flap  which  is  to 
be  drawn  under  A.  2.  The  flap  B  drawn  under  A  and  sutured;  D.  the  raw  area,  which 
should  be  grafted.  3.  Outline  of  pedicle  C.  The  lower  pedicle  of  flap  A  is  gradually 
severed.  The  pedicle  of  flap  B  is  cut,  and  the  double-faced  flap  A  is  then  shifted  to  the 
cheek. 

lips  and  are  carried  across  on  the  opposite  cheek  a  sufficient  distance 
to  loosen  the  flap  freely.  Then  the  flap  is  shifted  over  and  sutured  to 
the  margins  of  the  defect  in  layers.  The  mouth  is  now  much  dis- 
placed, but  after  healing  is  complete  it  is  returned  to  its  central  posi- 


FiG.  688. — Operation  for  closing  a  cheek  defect  (Lerda).^i.  The  cheek  defect.  The 
incisions  through  the  full  thickness  of  the  cheek  are  indicated  by  dotted  lines.  2  and  3. 
Mouth  and  cheek  of  opposite  side  shifted  over  to  fill  the  defect.  4.  The  defect  closed  and 
situation  of  the  mouth  changed  by  shortening  the  angle  on  one  side,  and  lengthening  on 
the  other. 

tion  by  lengthening  the  angle  away  from,  and  shortening  the  angle 
nearest  to  the  defect.  This  operation  is  not  to  be  recommended, 
although  it  may  be  used  occasionally  (Fig.  688). 


586 


PLASTIC    SURGERY 


Bardenheuer's  Operation. — This  very  mutilating  procedure  should 
be  considered  only  in  unusual  and  very  extensive  cases.  Two  flaps 
are  taken,  one  from  the  forehead,  with  the  pedicle  above  the  eye,  to 
line  the  cheek;  the  other,  or  covering  flap,  is  taken  from  the  side  of  the 
neck  with  the  pedicle  at  the  margin  of  the  lower  jaw.  The  flap  which 
is  utilized  to  replace  the  mucous  membrane  should  be  hairless.  The 
pedicles  are  divided  later,  and  secondary  operations  are  done. 

Monod  and  Vanverts'  Operation. — An  operation  similar  to  that 
just  mentioned  utilizes  a  forehead  flap  cut  in  much  the  same  way  as 


Fig.  689.  Pig.  690. 

Pig.  689. — Bardenheuer's  operation  for  closing  a  large  cheek  defect  (Binnie). — The 
large  flap  A  is  turned  down  from  the  forehead  to  fill  the  defect,  skin  side  inward,  and  the 
flap  B  from  the  neck  is  shifted  up  to  cover  it.  The  pedicles  are  cut  later  and  turned  back, 
and  all  raw  surfaces  are  grafted. 

Pig.  690. — Monod  and  Vanverts' operation  for  closing  a  large  cheek  detect  (Binnie) . — 
The  flap  A  from  forehead,  including  the  angular  artery,  is  turned  down  and  sutured  into 
the  defect,  skin  side  inward.  The  flap  B,  from  the  neck  is  raised  to  cover  it.  Later  the 
pedicles  are  cut  and  fltted  in  position.     All  raw  surfaces  are  sutured  or  grafted. 


for  reconstruction  of  the  nose,  the  pedicle  of  which  contains  the  angular 
artery.  The  long  pedicles  of  these  flaps,  after  being  severed,  should 
be  returned  to  their  original  position  (Figs.  689-690). 

Willard  Bartlett  in  1907  used  the  tongue  for  immediately  closing 
a  defect  in  the  cheek  following  excision  of  a  malignant  growth  of  the 
mucous  membrane.     The  greater  portion  of  the  mucous  membrane  m 
as  well  as  a  section  of  the  full  thickness  of  the  cheek,  was  excised. 
The  side  of  the  tongue  was  split  lengthways  and  the  edges  were  sutured    „ 


i 


SURGERY    OF    THE    CHEEK 


587 


to  the  margins  of  the  defect.  The  superficial  tissues  of  the  cheek 
were  closed.  The  mobility  of  the  tongue  is  so  great,  that  its  useful- 
ness was  not  impaired,  and  the  patient  could  eat,  talk  and  swallow 
without  difficulty  within  two  weeks.  The  teeth  on  the  operated  side 
(both  upper  and  lower)  were  missing,  and  if  this  operation  should  be 
decided  on  it  would  be  necessary  to  remove  the  teeth  before  utilizing 
the  tongue.  Practically  the  same  operation  was  used  by  Meissl  in 
1906  for  the  same  purpose  (Fig.  691). 


Mandible 


Fig.  6qi. — Operation  for  closing  a  cheek  defect  with  the  tongue  {Meissl). — i.  Frontal 
section  through  the  mouth  at  the  first  malar  tooth.  The  black  line  indicates  the  incision 
in  the  tongue  parallel  with  the  floor  of  the  mouth.  2.  The  split  tongue  sutured  to  the 
margin  of  the  cheek  defect.      The  raw  surface  may  be  covered  by  a  flap  or  by  grafts. 


CICATRICL\L  CONTRACTURE  OF  THE  JAWS 

In  many  old  cases  due  to  ulceration  or  extensive  trauma,  in  ad- 
dition to  the  cheek  defect  we  have  to  contend  with  a  locking  of  the 
jaws  due  to  cicatricial  contracture  of  the  tissues  of  the  cheek,  and  we 
are  called  upon  to  relieve  the  constriction  and  at  the  same  time  close 
the  cheek  defect.  Such  cases  are  very  difficult  and  in  many  instances 
it  is  impossible  to  obtain  more  than  a  partial  restoration  of  function. 
Hence,  il  is  much  better  to  try  to  prevent  tlw  formation  of  the  scar  than 
to  correct  it  after  it  is  formed. 

Unless  special  contraindications  exist  in  cases  of  extensive  de- 
struction of  the  tissues  of  the  cheek,  the  formation  of  this  contracture 


588  PLASTIC    SURGERY 

can  best  be  prevented  by  the  "open  bite"  method  of  treatment;  which 
should  be  insisted  upon.  The  "open  bite"  splint  with  the  smooth 
adjustable  shield  advocated  by  Cole  is  an  excellent  appliance.  By 
its  use  the  buccal  sulcus  is  preserved,  and  when  closure  cannot  be  ob- 
tained the  lips  of  the  wound  are  prevented  from  prolapse,  and  the  con- 
tour is  preserved.  Much  can  be  accomplished  by  keeping  the  jaws 
apart,  but  unfortunately  it  is  seldom  that  we  see  these  cases  until  the 
contracture  has  taken  place,  and  the  condition  has  existed  for  years. 

Among  operations  devised  for  relieving  the  contracture  and  at 
the  same  time  lining  the  cheek,   the  following  may  be  mentioned: 

Gussenbauer's  Operation.- — This  operation  is  applicable  in  cases 
of  comparatively  small  cheek  defects  with  locking  of  the  jaws  due 
to  scar  tissue.     It  is  done  in  stages. 

First  Stage  .^ — A  quadrilateral  flap  of  the  skin  of  the  cheek  (of 
the  desired  width)  extending  from  the  angle  of  the  mouth  to  the  mas- 


FiG.  692. — Operation  for  lining  the  cheek,  and  closing  a  cheek  defect  (Gussenbauer). — 
The  flap  X  is  raised  from  the  cheek  with  its  pedicle  at  the  anterior  border  of  the  masseter 
muscle.  The  scar  tissue  is  divided  from  the  angle  of  the  mouth  to  the  edge  of  the  masseter. 
2.  The  free  end  of  the  flap  turned  in  and  sutured  into  the  defect  at  the  inner  margin  of  the 
masseter. 

seter  muscle  is  dissected  up.  Its  free  end  is  in  front,  and  its  pedicle 
at  the  anterior  border  of  the  masseter.  The  cicatricial  tissue  beneath 
is  divided  from  the  angle  of  the  mouth  to  the  masseter,  and  the  mouth 
is  opened;  the  flap  is  folded,  skin  surface  inward,  and  the  anterior 
border  is  sutured  to  the  mucous  membrane  at  the  edge  of  the  masseter. 

Second  Stage. — Four  weeks  later  the  pedicle  is  cut;  the  external 
surface  (pedicle  end)  is  turned  inward  to  complete  the  lining  of  the 
cheek,  and  is  sutured  in  position. 

Third  Stage. — The  external  raw  surface  of  the  flap  may  be 
covered  by  shifting  skin  from  the  border  of  the  lower  jaw,  or  in  any 
way  deemed  advisable  for  the  special  case.  Secondary  operations 
will  be  necessary  (Figs.  692-693). 


SURGERY    OF    THE    CHEEK 


;89 


Nelaton  and  Ombredanne's  Operation.  First  Stage. — Excise 
with  horizontal  incisions  the  scar  tissue  on  the  affected  side  from  the 
angle  of  the  mouth  to  the  masseter  muscle.     A  flap  of  the  required 


Fig.  693. — Operation  for  lining  the  cheek,  continued. — i.  Two  weeks  later  the  pedicle 
of  the  flap  is  cut  and  the  outer  portion  is  unfolded  and  turned  in  to  line  the  anterior  part 
of  the  cheek.  2.  A  flap  with  pedicle  adjacent  to  the  defect  is  raised,  and  shifted  to  cover 
the  raw  surface.     Skin  defects  are  sutured. 

size  is  raised  from  the  inner  side  of  the  arm  with  its  pedicle  below; 
this  is  sutured  to  the  defect  in  the  mucosa,  skin  side  inward,  and  the 
arm  is  immobilized. 


Fig.  694. — Operation  for  lining  a  cheek  defect  (modified  from  Nelaton  and  Ombre- 
danne.). — i.  The  defect  is  lined  by  a  flap  X.  from  the  arm,  pedicle  below.  2.  After  two 
weeks  the  pedicle  Y  is  lengthened  and  cut,  and  turned  outward  to  cover  the  raw  surface  of 
the  portion  of  the  flap  first  implanted.      This  may  be  done  on  both  sides,  if  necessary. 

Second  Stage. — Three  weeks  later  the  pedicle  of  the  flap  on  the 
arm  is  lengthened  so  that  when  it  is  cut  it  can  be  folded  over  to  cover 
the  raw  surface  of  the  portion  first  inserted.     It  is  then  sutured  into 


590  PLASTIC    SURGERY 

position.     The  other  side  may  be  treated  in  a  similar  manner, 
ondary  trimming  operations  will  be  necessary.     The  arm  defect  ma> 
be  sutured  or  grafted  (Tig.  694). 

I  have  seen  cases  in  which  the  jaws  were  locked  so  tightly  that 
the  teeth  were  pushed  outward  and  buried  in  the  mass  of  scar  which  had 
fused  the  cheek  and  jaws  into  one  solid  immovable  piece.  In  these 
cases  an  effort  must  be  made  to  separate  the  cheek  from  the  alveolar 
processes;  then  to  line  the  cheek  and  gradually,  after  several  operations, 
to  loosen  the  jaw.  Sometimes  in  these  cases  excision  of  the  head  of  the 
bone  may  be  of  service,  but  this  alone  does  not  give  much  relief.  It 
may  be  used  in  connection  with  the  operation  of  Le  Dentu,  in  which  the 
insertion  of  the  masseter  and  the  internal  pterygoid  m.uscles  are  loosened 
from  the  mandible  with  excision  of  as  much  scar  tissue  as  possible,  and 
the  destroyed  mucous  membrane  is  replaced  by  whole-thickness  skin 
flaps.  The  excision  of  a  wedge  of  bone  on  each  side  of  the  mandible  in 
front  of  the  scar  bands,  as  advised  by  Esmarch  for  the  relief  of  complete 
anchylosis,  has  little  to  recommend  it,  although  it  may  be  tried  as  a 
last  resort. 

Stretching  the  Scar  Tissue.- — ]Many  forms  of  apparatus  have  been 
devised  for  stretching  scar  tissue  constricting  the  jaws,  but  unless  the 
scar  is  scanty,  little  can  be  accomplished  by  this  method.  However, 
after  division  of  the  scar,  as  suggested  by  Mott,  stretching  may  be 
effective,  if  continued  for  a  considerable  period. 


Angiomata 

Angiomata  of  the  cheek  or  lips  may  be  treated  by  methods  already 
described  in  the  section  on  this  subject. 


Depressed  Scars 

The  various  methods  of  treating  ordinary  scars  have  been  previously 
described.  In  the  extensive  depressed  scars  of  the  cheek  following 
wounds,  much  can  be  done  after  the  scar  has  been  excised  and  normal 
skin  has  been  sutured  to  normal  skin,  by  the  transplantation  of  fat  to 
fill  out  the  depression.  If  the  depression  is  in  the  region  of  the  zygoma- 
tic arch,  a  pedunculated  flap  of  the  temporal  muscle  may  be  shifted 
down  to  fill  it.  Sometimes  free  or  decalcified  bone,  implanted  in  the 
soft  parts  may  be  used  to  fill  in  the  depression. 

Pietri  has  used  with  success  pedunculated  flaps  of  fat  (after  Moure's 


SURGERY   OF    THE    CHEEK 


591 


i^od)  to  fill  out  defects  in  the  face.  According  to  the  situation  of  the 
depression  to  be  filled,  he  obtains  the  fat  from  the  chin,  between  the 
buccinator  and  masseter  muscles,  or  from  the  zygomatic  fossa.  I  have 
used  this  method  with  much  success. 

SALI\  ARY  FISTUL.^ 

Salivary  fistulae  are  quite  rare  in  civil  practice,  but  sometimes 
they  are  of  interest  to  the  plastic  surgeon  as  a  complication  in  the 
treatment  of  old  cheek  defects.  Considering  the  frequency  of  face 
wounds  in  this  war  they  are  fairly  uncommon,  although  Morestin 
reports  30  cases  of  the  glandular  t^-pe,  and  32  cases  of  fistulae  of 
Stenson's  duct  that  have  come  under  his  care  between  191 5  and  191 7. 

These  fistulre,  in  the  vast  majority  of  cases,  are  connected  with 
the  parotid  gland  or  its  duct,  and  may  be  divided  into  two  groups: 
(i)  Glandular  fistiil(E.     (2)  Fistulcc  of  Stenson's  duct. 

A  clean  incised  wound  into  the  parotid  gland  will  usually  heal 
spontaneously,  but  little  can  be  done  to  avoid  the  occurrence  of  fistulae 
in  war  wounds  of  the  parotid,  because  they  are  so  frequently  complicated 
by  infection.  The  condition  is  usually  well  established  and  the  diag- 
nosis clear  by  the  time  the  patient  is  referred  to  the  plastic  surgeon. 

In  all  recent  wounds  involving  the  cheek,  if  Stenson's  duct  can  be 
located  it  should  be  immediately  fixed  in  position,  so  that  it  will  discharge 
into  the  mouth. 

Glandular  fistulae  may  occur  anywhere  over  the  parotid  gland, 
those  in  the  upper  or  lower  portion  being  much  less  difticult  to  cure 
than  those  opening  into  the  main  collecting  channels  which  are  situated 
at  the  junction  of  the  upper  and  middle  thirds  close  to  the  anterior 
border.  In  operating  on  fistula?  every  efl'ort  should  be  made  to  avoid 
injury  to  branches  of  the  facial  nerve  and  the  larger  vessels. 

Treatment  of  Glandular  Fistulae.^ — Immobilization  of  the  jaws 
has  been  recommended,  and  Pietri  reports  38  cases  cured  by  this 
method.  The  jaws  are  held  together  sometimes  for  several  months 
with  intermaxillary  ligatures,  splints,  or  by  means  of  a  bandage  which 
prevents  the  jaws  being  opened.  Liquid  nourishment  is  given  and 
speaking  is  prohibited.  .\s  the  fistula  closes  the  diet  is  gradually 
increased. 

Dieulafe  says  that  many  cases  will  heal  spontaneously  without 
immobilization  of  the  jaws,  and  that  the  fistula  persists  just  as  often 
in  those  who  have  been  subjected  to  immobilization  as  in  those  who  have 


592 


PLASTIC    SURGERY 


not  had  the  jaws  closed.  Be  that  as  it  may,  since  the  method  is 
simple,  it  should  be  tried  in  conjunction  with  cauterization. 

Glandular  fistulas  may  be  treated  by  cauterization  with  silver 
nitrate  or,  better  still,  with  the  actual  cautery.  The  cautery  may  be 
applied  directly  to  the  fistulous  tract  every  few  days,  or  the  application 
may  be  made  through  a  small  incision  above  and  below  the  fistula, 
until  the  tract  is  removed  and  the  wound  closed. 

Extensive  avulsion  of  the  auriculo-temporal  nerve  (which  is  found 
between  the  temporal  artery  and  the  ear)  may  be  done  for  the  pur- 
pose of  diminishing  the  secretion  of  the  gland,  and  a  number  of  good 


123  4 

Pig.  695. — Hemangioma  of  the  cheek. —  i  and  2.  Before  operative  interference.  The 
growth  extended  from  the  ear  to  the  midhne  of  the  lip.  The  lower  lid  and  side  of  the  nose, 
and  also  the  mucous  membrane  of  the  mouth  on  the  right  side  were  involved.  3.  Photo- 
graph taken  six  weeks  later.  4.  Taken  four  months  after  the  first  operation.  There  has 
been  considerable  improvement.  Several  further  operations  will  have  to  be  done.  The 
bones  on  the  right  side  of  the  face  are  also  markedly  hypertrophied  and  the  necessary 
portions  will  have  to  be  removed  before  symmetry  can  be  brought  about.  Little  could  be 
accomplished  by  injections  in  this  case  as  there  is  considerable  fibrous  tissue  scattered 
through  the  growth. 


results  have  been  reported  by  this  method  (Leriche,  Deupes,  Dieu- 
lafe,  Tromp,  lanni,  and  others). 

The  fistulous  tract  may  be  excised,  and  the  wound  carefully  closed 
in  layers,  so  as  to  leave  no  dead  space.  Morestin  found  that  24  of 
the  26  cases  treated  by  this  method  healed  without  complications, 
and  considers  extirpation  the  method  of  choice.  In  one  case  fluid 
collected  in  the  wound;  this  was  aspirated,  whenever  necessary,  and 
pressure  applied.  The  wound  healed  promptly.  In  the  other, 
infection  occurred  but  the  final  result  was  good.  In  the  cases  follow- 
ing war  wounds  in  which  the  fistula  is  in  the  midst  of  dense  scar  tissue 
(adherent  and  depressed),  it  is  important  that  all  the  scar  be  removed. 
In  these  the  cure  of  the  fistula  can  be  accomplished  as  an  incident  in 


SURGERY    OF    THE    CHEEK 


593 


PAROTID 


the  operations  for  removing  the  disfiguring  scar  tissue.  Sometimes 
it  may  be  necessary  to  extirpate  the  entire  gland,  but  this  should  not 
be  done  until  all  other  methods  have  failed. 

Submaxillary  glandular  fistulae  are  very  rare  as  compared  with 
those  of  the  parotid.     For  these  extirpation  is  the  operation  of  choice. 

Fistulae  of  Stenson's  Duct. — Dieulafe  has  found  three  forms  fol- 
lowing war  wounds,  (i)  Fistulae  caused  by  lateral  section  of  the 
duct,  with  limited  traumatism  of  the  cheek.  (2) 
Fistulae  caused  by  great  destruction  of  the  cheek, 
followed  by  contracted  scars  which  occlude  the 
duct,  obliterating  its  normal  orifice  and  lea\'ing 
open  the  skin  wound.  This  is  the  most  common 
variety.  (3)  Fistulae  of  the  duct  caused  by  infec- 
tion associated  with  destructive  traumatism  in- 
volving bone  and  soft  parts. 

Many  operations  have  been  devised  for  the  re- 
lief of  this  condition.  The  object  of  these  opera- 
tions is  to  divert  the  flow  of  parotid  secretion  into 
the  mouth  from  its  abnormal  external  point  of  dis- 
charge. If  this  cannot  be  done  by  any  of  the 
means  at  our  command,  it  may  be  deemed  advis- 
able to  check  the  secretion  entirely. 

Operations  for  the  relief  of  fistulae  of  Stenson's 
duct  vary  with  the   position   of   the   fistula;    (i)  A  wire  or  rubber  liga- 

•' ^  '^  cure    IS    inserted    from 

w^hen  it  is  anterior  to  the  masseter  muscle;  (2)  the  buccal  surface  so 
when  it  is  in  the  masseteric  portion  of  the  duct 


Fig.  696. — Opera- 
tion for  fistula  of  Sten- 
son's duct   (De guise). — 


When  the  Fistula  is  Anterior  to  the 
Masseter  Muscle 


IS 


that  it  passes  through 
the  floor  of  the  fistula. 
It  is  tied  or  twisted 
tightly,  and  the  tissue 
included  will  slough, 
thus  making  an  opening 
into  the  mouth.  The 
fistulous  tract  is  then  ex- 
cised and  the  edges  are 
closed. 


Von  Langenbeck's  Operation. — A  probe 
passed  through  the  fistula  into  the  portion  of  the 
duct  next  to  the  gland.  The  duct  having  been  dissected  out  its  free 
end  is  drawn  through  an  opening  into  the  mouth,  and  sutured  to  the 
buccal  mucosa.  The  external  wound  is  closed.  This  is  the  operation 
of  choice  when  the  duct  is  anterior  to  the  masseter,  but  unfortunately 
the  fistulae  are  usually  found  much  further  back. 

Deguise's  Operation.— From  the  fistula  make  two  perforations 
0.625  cm.  {}^  inch)  apart  into  the  mouth.  Pass  through  these  per- 
forations an  elastic  ligature,  a  silver  or  lead  wire,  or  a  silk  ligature,  and 

3S 


594  PLASTIC    SURGERY 

tie  snugly  inside  the  mouth.  The  tissue  included  in  this  ligature  will 
necrose,  and  a  permanent  opening  will  result.  When  this  is  assured, 
excise  the  fistulous  tract  in  the  skin,  and  close  the  external  wound 
(Fig.  696). 

Kaufmann's  Operation. — Thrust  a  cannula  about  0.312  cm.  (3-^ 
inch)  in  diameter  through  the  fistula  into  the  mouth,  and  through  it 
pass  a  rubber  tube  or  a  seton.  Remove  the  cannula  and,  after  the 
tract  around  the  tube  has  been  covered  with  epithelium,  freshen  the 
skin  edges  and  close  the  external  wound. 

2.  When  the  Fistula  is  Situated  in  the  Masseteric  Portion  of  Stenson's 

Duct 

Von  Langenbeck's  operation  may  be  used  if  the  duct  is  long  enough 
and  can  be  brought  through  a  transverse  incision  in  the  masseter 
to  the  buccal  mucous  membrane.  The  methods  of  Kaufmann  and 
Deguise  may  also  be  used,  but  the  masseter  should  not  be  punctured, 
and  the  seton,  stitch,  or  rubber  drain  should  be  passed  through  a 
tunnel  burrowed  between  the  masseter  and  the  skin. 

Braun's,  or  Kiittner's  Operation. — A  new  duct  is  formed  with  a 
pedunculated  flap  from  the  buccal  mucosa.  Through  a  skin  incision 
a  flap  of  mucous  membrane  of  sufficient  length  to  bridge  the  defect 
without  tension  is  raised  in  front  of  the  masseter,  with  its  pedicle  at 
the  anterior  border  of  this  muscle.  It  is  turned  back  over  the  edge  of 
the  masseter,  its  free  end  is  sutured  to  the  stump  of  the  duct,  which  has 
been  freely  mobilized,  and  the  edges  of  the  flap  are  brought  together 
to  form  a  sort  of  tube.  The  skin  is  then  closed.  This  operation  is 
said  to  be  effective  (Fig.  697). 

Grouse's  Operation. — A  vertical  incision  3.  cm.  (1I5  inch)  long 
is  made  through  skin  and  fat,  2.  cm.  {%  inch)  below  the  zygomatic 
process,  and  2.  cm.  {f^  inch)  in  front  of  the  ear.  This  incision  avoids 
injuring  nerves  and  vessels.  The  parotid  fascia  is  exposed,  and  an 
incision  i.  cm.  (%  inch)  long  is  made  in  it.  The  cheek  is  then  everted, 
and  a  pedunculated  flap  of  buccal  mucous  membrane  0.625  cm.  {}-^ 
inch)  wide  (I  would  suggest  a  slightly  wider  flap),  and  0.312  cm. 
(}-i  inch)  thick,  is  raised.  The  free  end  should  be  close  to  the  vermi- 
lion line  of  the  upper  lip,  and  the  base  opposite  the  cusp  of  the  second 
upper  molar  tooth.  Then  with  a  curved  clamp  a  tunnel  is  burrowed 
between  the  skin  and  the  masseter  muscle,  the  clamp  is  passed  over  the 
anterior  border  of  the  masseter,  punctures  the  buccinator,  and  enters 


SURGERY   OF    THE    CHEEK 


595 


the  mouth  just  in  front  of  the  base  of  the  pedunculated  mucous  mem- 
brane flap.  The  flap  is  then  drawn  through  this  tunnel,  and  its  tip 
is  sutured  into  the  incision  in  the  parotid  fascia  with  a  moditied 
Lembert  suture  of  No.  o,  lo-day  chromic  catgut,  which  pulls  it  in. 


P  "" 


"^'^tu, 


Pig.  697. — Braun's  operation  for  fistula  of  Stenson's  duct  (Binnie). — i.  Make  the 
incision  AB  which  divides  all  the  tissues  except  the  masseter,  and  the  buccal  mucosa.  Dis- 
sect the  fistulous  opening  free  from  the  skin.  2.  Retract  the  tissues  and  form  a  flap  of 
mucosa  of  the  desired  length  and  width,  with  its  pedicle  at  the  anterior  border  of  the 
masseter.  3.  Turn  the  flap  back  and  suture  its  free  end  to  the  fistula,  and  its  edges  to- 
gether to  form  a  tube.     Close  the  skin  wound. 

The  ends  of  this  suture  are  left  long,  and  to  it  is  tied  a  loop  of  Xo.  5, 
lo-day  chromic  catgut  which  is  passed  in  from  the  mouth  along  the 
flap  (the  ends  being  left  in  the  mouth).  The  mucous  flap  assumes  a 
channel-like  form,  and  it  may  be  wise  to  draw  the  edges  together  with 
a  stitch  or  two,  in  order  to  form  a  sort  of  tube  over  the  catgut  strands. 


596 


PLASTIC    SURGERY 


This  is  an  excellent  operation  and  with  modifications  is  well  worth 
trying  (Figs.  698-699). 


Pig.  698. — Operation  for  fistula  of  Stenson's  duct  (Crouse). — i.  The  skin  is  retracted 
and  the  fascia  over  the  parotid  is  exposed.  Note  the  clamp  which  is  passfed  beneath  the 
skin  and  over  the  anterior  margin  of  the  masseter  muscle.  2.  The  cheek  turned  out  and 
a  thick  flap  of  mucous  membrane  and  submucous  tissue  is  raised,  itte  pedicle  being  opposite 
the  second  molar  tooth.      The  insert  shows  the  closure  of  the  mucous  membrane. 


^ 


Pig.  699. — Operation  for  fistula  of  Stenson's  duct,  continued,  i.  The  mucous  flap 
drawn  through  the  tunnel  made  by  the  clamp.  Note  the  modified  Lembert  suture  which 
will  draw  the  tip  of  the  flap  under  the  edge  of  the  slit  in  the  parotid  fascia.  Note  the  gutter- 
shape  assumed  by  the  flap.  2.  The  loop  of  ten-day  catgut  lying  in  the  bottom  of  the 
gutter  is  tied  to  the  Lembert  suture.  A  few  sutures  placed  in  the  margins  of  the  flap  will 
tend  to  form  a  tube. 

Anastomosis  Between  the  Parotid  and  Submaxillary  Glands. — 

Ferrarini's  suggestion  of  forming  an  anastomosis  between  glandular 
portions  of  the  parotid  and  submaxillary  glands  in  cases  of  fistulae 
of  Stenson's  duct  does  not  appear  to  be  practical.     The  restoration  of 


SURGERY   OF    THE    CHEEK  597 

the  duct  by  means  of  a  segment  of  vein,  or  by  a  skin  graft,  has  also  been 
tried,  but  these  methods  cannot  be  commended. 

It  has  been  known  for  some  time  that  when  Stenson's  duct  has  been 
obliterated  by  scar  tissue  close  to  the  gland  the  gland  will  atrophy, 
and  this  probably  occurs  after  healing  in  extensive  wounds  more  fre- 
quently than  we  have  realized.  The  secretion  that  pours  out  of  the 
fistula  is,  of  course,  lost  as  far  as  digestive  processes  are  concerned, 
although  this  loss  causes  no  perceptible  disadvantage  to  the  patient. 
Morestin,  noting  this  fact,  in  treating  his  cases  of  fistulas  of  Stenson's 
duct  in  which  there  was  no  possibility  of  successful  implantation  on 
the  buccal  surface,  dissects  out  the  stump  of  the  duct  with  all  the  sur- 
rounding tissue,  ligates  it  at  its  origin,  after  which  he  mobilizes  the 
soft  parts  and  closes  without  drainage.  The  obliteration  of  the  duct 
causes  rapid  physiological  death  of  the  gland,  but  the  patient  is  no 
worse  off  than  when  the  secretion  was  being  discharged  upon  the  cheek. 
Morestin  is  enthusiastic  over  the  method,  and  out  of  32  cases  of  fis- 
tulas of  Stenson's  duct  in  war  wounds  treated  i6  by  the  establishment 
of  drainage  into  the  buccal  cavity,  and  13  by  ligating  the  duct  close  to 
the  gland.  (The  remaining  3  cases  were  done  by  other  methods.) 
His  experience  has  led  him  to  conclude  that  the  latter  method  is  the 
best,  and  he  has  decided  to  use  it  exclusively  in  all  suitable  cases. 

Although  supported  by  various  authors,  one  would  hardly  feel 
justified  in  avulsing  the  auriculo-temporal  nerve,  or  in  extirpating 
the  parotid  gland  for  the  cure  of  a  fistula  of  Stenson's  duct  when 
simpler  methods  will  accomplish  the  same  purpose. 

FACIAL  PAR.ALYSIS 

The  cases  of  facial  paralysis  which  come  to  the  plastic  surgeon  are 
either  those  of  very  long  standing,  those  in  which  nerve  anastomosis 
(facial  to  spinal  accessor^-,  or  facial  to  h^-poglossal)  has  been  unsuccess- 
ful, or  those  in  which  the  extent  of  the  destruction  has  precluded  nerve 
anastomosis. 

The  technic  of  nerve  anastomosis,  which  is,  of  course,  the  method 
of  choice  when  practical,  will  not  be  considered  here;  for  full  details  of 
the  method  the  reader  is  referred  to  the  following  articles:^ 

*  B.\LLAN-CE,  C.  H.,  Ballaxce,  H.  a.,  &  Stewart,  P.    "Brit.  :Med.  Jour.,"  1903.  i,  1009. 
Ballanxe.  C.  H.     "'Lancet."'     London.  June  12,  1909,  1675. 
Beckmax,  E.  H.     "ilichigan  State  Med.  Soc.  Jour.,"  Dec,  1914. 
CuSHiXG,  H.     "Anns.  Surg.,"  May,  1903,  641. 
DoRi,  L.     "Riforma  Med.,"  Oct.  30,  191 1. 


598 


PLASTIC    SURGERY 


The  paralysis  may  be  due  to  any  cause  (injury  or  disease)  by 
which  the  continuity  of  the  nerve  is  broken.  The  muscles  are  atro- 
phied and  flabby  and  no  longer  respond  to  the  faradic  current;  the 
angle  of  the  mouth  droops  and  there  is  constant  drooling  of  saliva; 
the  mucous  membrane  of  the  cheek  is  frequently  caught  between  the 
teeth;  speech  may  be  impaired  on  account  of  the  lack  of  control  of 
the  lips;  the  lower  eyelid  is  everted;  conjunctivitis  is  chronic,  and 

lachrymation  is  continuous. 

The  facial  nerve  may  be  accidently 
cut,  or  a  section  of  it  be  excised  during 
operations  for  removal  of  glands  of  the 
neck  and  quite  a  number  of  such  cases 
have  come  under  my  observation  years 
after  the  accident.  The  patients,  of 
course,  desire  improvement  in  their 
appearance,  but  many  of  these  pa- 
tients have  become  more  or  less  ac- 
customed to  their  deformity  and  simply 
desire  the  angle  of  the  mouth  to  be 
raised  to  overcome  drooling,  and  the 
Fig.    700.— Myeiopiasty  for    facial  lowcr  eyelid  adjusted  for  the  protec- 

saralysis    (Eden). — Schematic     drawing      .  t   t-'U  Tf  '  ^1 

showing  the  skin  incisions  A  in  the  hair    ^lOU  01    ttie  eye.       it  IS  neeaieSS  tO  Say 

line,  and  B  in  the  nasolabial  fold.    D,   that  if  these  two  dcfccts  cau  be  rcme- 

the    temporal  muscle.      D',   a   peduncu- 
lated flap  of  the  temporal  muscle  at-  died  the  appearance  is  also  much  im- 

tached  to  the  orbicularis  palpebrarum.  ■p.-Mp.-.rpf^ 

C,   the  masseter  muscle.      C,   a  flap  of  PrOVea. 

the  masseter  split  and  attached    above 

and  below  the  angles  of  the  mouth.  ELEVATION  OF  LOWER  EYELID 

The  eyelid  may  be  raised  by  one  of  the  plastic  operations  already 
described  for  the  relief  of  ectropion,  or  by  means  of  a  pedunculated 
flap  from  the  temporal  muscle. 

Operation  for  Raising  the  Lower  Eyelid  by  the  Attachment  of  a 
Pedunculated  Flap  of  the  Temporal  Muscle  to  the  Orbicularis  Palpe- 
brarum (Modified  after  Lexer  and  Morestin). — A  curved  incision 
about  7.  cm.  {2%  inches)  long  is  made  along  the  anterior  border  of  the 
temporal  fossa;  a  bundle  of  fibers  is  separated    from  the  temporal 

Frazier  &  Spiller.     "Univ.  of  Penn.  Med.  Bull.,"  1903. 

Grant,  W.  W.     "Jour.  Amer.  Med.  Assn.,"  Oct.  22,  1910,  1438. 

Rothschild,  O.     "  Centralbl.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,"  Dec.  21,  1911,  823. 

Sharpe.  W.     "Jour.  Amer.  Med.  Assn.,"  May  11,  1918,  1354. 

Watts,  S.  H.     "Old  Dominion  Jour,  of  Med.  &  Surg.,"  June,  1913,  259. 


SURGERY   OF    THE    CHEEK  599 

muscle  with  its  pedicle  above.  The  orbicularis  palpebrarum  is  found 
and  the  muscle  flap  is  sutured  to  it  at  the  angle,  or  along  the  lower  lid, 
in  such  a  manner  as  to  raise  the  lower  lid.  The  wound  is  then  closed 
(Fig.  700). 

ELEVATION  OF  ANGLE  OF  MOUTH 

A  number  of  ingenious  operations  have  been  devised  for  raising 
the  angle  of  the  mouth,  some  of  which  are  quite  satisfactory. 

The  angle  may  be  raised  to  the  desired  position  with  a  strip  of  free 
fascia  lata  (Stein,  and  others);  with  thin  wire  (Busch,  Momburg, 
and  others) ;  or  silk  looped  over  the  zygomatic  arch.  This  may  also 
be  accomplished  by  implanting  the  end  of  a  living  muscle  (the  sterno- 
cleidomastoid, J.  Jianu,  Gomoiu,  Hildebrand,  and  others;  the  masseter, 
A.  Jianu,  Jonnescu,  Lexer,  and  others;  or  the  digastric,  J.  Jianu), 
into  the  orbicularis  oris  at  the  angle  of  the  mouth.  Morestin  sutures 
the  buccinator  muscle  to  the  anterior  border  and  aponeurosis  of  the 
masseter  muscle. 

RAISING  THE   ANGLE   OF   THE   MOUTH   IN   FACIAL 
PARALYSIS    BY    MYELOPLASTY 

The  Use  of  a  Pedunculated  Flap  of  the  Sternocleidomastoid  Muscle. 
— The  upper  portion  of  the  sternocleidomastoid  is  exposed  and  a  flap  is 
raised  from  its  anterior  border,  base  upward.  Through  the  same 
incision  a  tunnel  is  burrowed  to  the  orbicularis  oris  muscle,  and  through 
a  small  skin  incision  close  to  the  angle  of  the  mouth  the  end  of  the  muscle 
flap  is  drawn  through  the  tunnel  and  sutured  into  position.  The  skin 
incisions  are  then  closed.  The  posterior  belly  of  the  digastric  muscle 
has  been  used  for  the  same  purpose  in  much  the  same  manner. 

The  Use  of  a  Pedunculated  Flap  of  the  Anterior  Portion  of  the  Mas- 
seter Muscle  (A.  Jianu). — The  use  of  a  muscle  flap  from  the  masseter 
muscle  is  much  simpler,  and  seems  to  me  more  rational.  (The  mas- 
seter is  supplied  by  the  masseteric  branch  of  the  fifth  nerve.)  The 
masseter  muscle  is  exposed  through  a  curved  incision  following  the  edge 
of  the  inferior  maxilla,  and  its  anterior  portion  is  separated  from  the 
bone  as  a  flap  with  its  pedicle  above.  The  skin  is  retracted,  under- 
mined if  necessary,  and  the  flap  in  one  piece  is  sutured  to  the  orbicularis 
oris  at  the  angle  of  the  mouth  or,  if  split,  is  sutured  above  and  below. 
The  skin  is  closed  (Figs.  701-702). 

Lexer  approaches  the  masseter  through  an  incision  in  the  naso- 


6oo 


PLASTIC    SURGERY 


labial  fold;  he  raises  a  flap  similar  to  that  just  described,  and  inserts 
it  in  the  same  manner. 


Fig.  701. — Operation  for  raising  the  angle  of  the  mouth  in  facial  paralysis  by  the  use 
of  a  pedunculated  flap  of  the  masseter  muscle  (A.  Jianu). — i.  Dotted  lines  represent  the 
outline  of  the  inferior  maxilla.  The  solid  line  indicates  the  curved  incision.  2.  A,  the 
portion  of  the  masseter  muscle  still  attached  to  the  bone.  B,  the  flap  of  the  anterior  portion 
of  the  masseter.      C,  the  buccinator  muscle.      D,  the  parotid  gland.     E,  the  inferior  maxilla. 

The  muscle  flap  operations  are  extremely  useful  and  offer  a  chance 
of  improvement  together  with  movement  of  the  mouth,  to  patients  on 
whom  nerve  anastomosis  has  failed. 


Fig.  702. — A.  Jianu's  operation  for  utilizing  a  flap  of  the  masseter  muscle,  continued. — 
r.  A  single  flap  B  sutured  into  the  angle  of  the  mouth.  2.  The  flap  B  split  and  sutured 
above  and  below  the  angle  of  the  mouth. 

When  the  living  muscle  flap  is  used,  the  associated  movements  may 
be  objectionable,  but  with  training  the  lip  may  be  moved  and  even  the 
facial  expression  may, be  obtained. 


SURGERY    OF    THE    CHEEK  6oi 

Morestin's  Operation. — Through  an  incision  5.  cm.  (2  inches) 
long  under  the  angle  of  the  jaw,  the  anterior  portion  of  the  masseter 
muscle  is  exposed.  The  buccinator  muscle  is  found  and  shortened  with 
sutures.  It  is  then  fastened  to  the  anterior  border  and  external 
face  of  the  masseter  by  sutures  placed  to  raise  the  angle  of  the 
mouth  to  the  desired  position. 

Morcstin  claims  to  have  had  good  results  with  this  method.  Before 
performing  this  operation  it  must  be  borne  in  mind  that  the  buccinator 
muscle  is  supplied  by  the  facial  nerve. 

My  own  preference  is  for  a  flap  of  the  masseter  muscle,  or  for  the 
use  of  the  buccinator  rather  than  for  the  flap  from  the  sternocleidomas- 
toid or  digastric  muscles,  as  the  direction  of  pull  is  too  low  with  the  last 
two  mentioned.  If  the  myeloplastic  operations  fail,  we  have  the  simpler 
methods  which  follow. 

Stein's  Operation.  Transplantation  of  Free  Fascia. — Three  weeks 
before  transplantation  a  small  amount  of  paraffm  is  injected  near  the 
angle  of  the  mouth,  in  order  to  prepare  a  firm  hold  for  the  fascia. 
Then  a  strip  of  fascia  lata  20.  cm.  (8  inches)  long  by  2.  cm.  {% 
inch)  broad,  is  removed.  Through  an  incision  over  the  malar  bone  a 
tunnel  is  burrowed  down  to  the  angle  of  the  mouth.  A  small  incision  is 
then  made  near  the  angle  and  the  loop  of  fascia  is  passed  around  the  paraf- 
fin injected  tissue.  After  the  angle  has  been  raised  to  the  desired  posi- 
tion, the  ends  are  sutured  around  the  zygomatic  arch;  the  wounds  are 
then  closed.  The  fascia  does  not  stretch  and  will  live  when 
transplanted. 

By  this  method,  which  with  modifications  is  a  good  one,  much 
can  be  accomplished.  A  single  strip  of  fascia  may  also  be  used  with 
satisfaction. 

Momburg's  Operation.  {The  Modified  Busch  Operation) — Through 
an  incision  along  its  lower  border  the  malar  bone  is  exposed;  a  second 
incision  is  made  parallel  to  the  mouth,  just  above  the  angle,  and  a 
thin  aluminium  bronze  wire  is  passed  through  the  cheek  tissues,  with 
a  special  needle,  from  above  downward.  A  broad  hold  having  been 
taken  near  the  mouth,  the  wire  is  returned  through  the  tissues  of  the 
cheek  and  is  passed  around  the  zygomatic  arch,  where  it  is  secured 
after  the  lip  has  been  raised  to  the  desired  height  (Fig.  703). 

This  dift'ers  from  the  Busch  operation  in  that  the  wire  is  passed 
around  the  malar  bone,  instead  of  through  a  hole  bored  in  it,  and  the 
amount  of  tissue  included  in  the  loop  at  the  angle  of  the  mouth  is 


6o2 


PLASTIC    SURGERY 


greater.  The  same  operation  may  be  done  with  waxed  silk,  which 
is  more  flexible. 

By  the  use  of  fascia,  wire,  or  silk,  the  angle  of  the  mouth  can  be 
raised  as  described,  and  the  drooling  controlled,  but  there  will  be  no 
motion. 

In  all  of  the  old  cases  there  is  a  great  deal  of  lax  skin,  and  I  have 
found  it  advisable  to  remove  suitable  areas  of  it,  in  addition  to  the 
radical  procedures. 

It  is  well  to  realize  that  the  skin  of  old  cases  of  facial  paralysis 
tends  to  stretch  and  has  little  power  of  resisting  infection.  The 
scar  after  healing,  is  apparently  prone  to  stretch  much  more  than  a 
scar  in  normal  skin. 


I  2 

Pig.  703. — The  use  of  a  wire  loop  for  raising  the  angle  of  the  mouth  in  facial  paralysis. 
(Momburg). — i.  The  position  of  the  wire  passed  through  a  perforation  in  the  zygomatic 
arch  (Busch).     2.   The  position  of  the  wire  passed  over  the  zygomatic  arch  (Momburg). 


In  all  of  these  methods  where  tunnelling  through  the  tissues  of 
the  cheek  is  necessary,  it  is  advisable  to  place  the  fingers  inside  the 
mouth,  so  that  the  progress  of  the  tunnelling  instrument  may  be 
followed  and  perforation  of  the  mucous  membrane  avoided. 

Lawen  has  implanted  pieces  of  free  bone  into  both  upper  and  lower 
lips  to  hold  them  in  position  in  cases  of  congenital  facial  paralysis. 
I  do  not  consider  this  method  of  any  special  value,  but  if  the  procedure 
is  used  cartilage  should  be  implanted  and  not  bone. 

After  these  operations  the  part  should  be  kept  absolutely  quiet 
until  healing  is  complete.  Liquid  diet  should  be  given  for  at  least 
two  weeks. 


SURGERY    OF    THE    CHEEK  603 

BIBLIOGRAPHY 

Cheek 
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B.\RDENHEUER.     "Verb.  d.  deutsch.  Gesellsch.  f.  Chir.,"  1891. 
Bartlett,  W.     "Anns.  Surg.,"  April,  1907,  573. 
BiNNiE,  J.  F.     "Operative  Surgery,"  7th  Ed.,  105. 

Cheyxe  &  BcRGHARD.     "A  System  of  Operative  Surgery,"  iii,  497. 
Cole,  P.  P.     "Lancet."    London,  March  17,  1917,  415. 

"Lancet."     London,  Jan.  5.  1918,  11. 

"Practitioner."     London,  June,  1918,  461. 
CzERXY,  V.     "Beitrag.  z.  klin.  Chir.,"  1889,  Bd.  4,  621. 

EssER,  J.  F.  S.     "Anns.  Surg.,"  March,  191 7,  297. 
"Surg.,  G}-ne.  &  Obst.,"  June,  191 7,  737. 
"Xew  York  !Med.  Jour.,"  Aug.  11,  1917,  264. 

Gersuxy,  R.     "Centralbl.  f.  Chir.,"  Sept.  17,  1887.  706. 
GussEXBAi-ER.     "Arch.  f.  Klin.  Chir.,"  1877,  526. 

V.  H.-VCKER.     '"Wien.  klin.  Wchnschr.."  Jan.  13,  1910,  48. 

"Beitrag.  z.  klin.  Chir.,"  1916,  289. 
Hahx.     "Verb.  d.  deutsch.  Gesellsch.  f.  Chir.,"  1887,  i,  102. 
HoRSLEY.     "Jour.  Amer.  Med.  Assn.,"  Jan.  30,  1915,  408. 

Israel,  J.     "Arch.  f.  klin.  Chir.,"  Bd.  36,  1887,  372. 
"Centralbl.  f.  Chir.,"  June  18,  1887,  37. 
"Anns.  Surg.,"  vi,  1887,  499. 

Kolle,  F.  S.     "Plastic  and  Cosmetic  Surgery,"  1911,  198. 
KoRTEWEG,  J.  A.     "Anns.  Surg.,"  July,  1891,  21. 
Kraske.     "Naturforscherversammlung,"  1888. 

Lauenstein,  C.     "Anns.  Surg.,"  May,  1893,  574. 
Lefevre  H.     "Archiv  Generales  de  Chir."     Paris,  Feb.,  1913,  148. 
Lerda,  G.     "Deutsch.  Zeitschr.  f.  Chir.,"  Feb.,  1913,  Nos.  1-2,  126. 

Lexer.     Bergmann  &  von  Bruns:  "Handbuch  d.  Praktischen  Chir.,"  i,  442.     (Exten- 
sive bibliography.) 
"Archiv  f.  klin.  Chir.,"  1910,  xcii,  749. 

Maxwarixg.     "Jour.  Amer.  ^led.  Assn.,"  Jan.  25,  1913,  278. 
Meissl,  T.     "Arch.  f.  klin.  Chir.,"  Bd.  78,  1906,  818. 
MoxoD,  Ch.  &  Vax~\erts,  J.     "Technic  Operatoire,"  1908,  ii,  38. 

MoRESTix,  H.     '•Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1915,  pp.  1217,  1550,  1627,  2240, 
2244. 

"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1916,  pp.  858,  1005,  1379. 

"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1917,  pp.  298,  357,  437,  1402,  1407- 
MoTT,  V.     Velpeau,  A.  L.  M.:  "Xew  Elements  of  Operative  Surgery,"  1847,  iii,  1139. 

Nelatox,  Ch.   &  Ojibredaxxe.     "Les  Autoplasties."     Paris,  1907,  109. 

PiETRi,  P.     "Pressemed."     Paris,  191 7,  xxv,  388. 


6o4  PLASTIC    SURGERY 

Roberts,  J.  B.     "Surg.,  Gyne.  &  Obst.,"  Jan.,  191 1,  24. 

"Surg.,  Gyne.  &  Obst.,"  Oct.,  1918,  369. 
RocKEY,  A.  E.     "Jour.  Amer.  Med.  Assn.,"  July  20,  1918,  183. 
Ruth,  F.  W.     "Jour.  Amer.  Med.  Assn.,"  May  10,  1902,  1203. 

Schmieden.     "Therap.  Monatsche."     Berlin,  May,  1913,  347. 

Semken,  G.  H.     "Med.  Rec."     New  York,  191 7,  xcii,  217. 

SoucHON,  E.     "Surg.,  Gyne.  &  Obst.,"  Aug.,  1911,  169. 

Staffel.     "Deutsche  med.  Wchnschr.,"  1890,  Nr.  50,  p.  1153. 

Stone,  J.  S.     Bryant  &  Buck:  "American  Practice  of  Surgery,"  vol.Jv,  p.  638. 

Tyler,  G.  T.     "Southern  Med.  Jour.,"  Dec,  1913,  797. 

Van  Hook,  W.     "Jour.  Amer.  Med.  Assn.,"  Oct.  6,  1917,  1140. 
VoECKLEE,  Th.     "Deutsche  Zeitschr.  f.  Chir.,"  Feb.,  1918,  305. 

Wade,  R.     "Lancet."     London,  1918,  i,  794. 


Salivary  Fistula 

Braun.     Quoted  by  Binnie:  "Operative  Surgery,"  7th  Ed.,  178. 

Grouse,  H.     "Surg.,  Gyne.  &  Obst.,  "  May,  1915,  593. 

Daily  Review  of  the  Foreign  Press,  April  i,  1918,  pp.  83-84. 
DEGxnsE,  F.     "J.  de  med.  Chir.  Pharm.,  etc."     Paris,  1811,  xxi,  271. 
Deupes.     "  Restauration  maxillo-faciale,"     Paris,  191 7,  189. 
DiEULAFE,  L.     "Restauration  maxillo-faciale,"     Paris,  1917,  197. 

"Paris  Med.,"  March  16,  1918,  No.  11,  211. 
DuPLAY,  S.  &  Reclus,  p.     "Traite  de  Chirurgie."     Paris,  v,  264. 

Ferrarini,  G.     "Zent.  f.  Chir.,"  June  13,  1914)  1017. 
Ianni,  R.     "Riforma  Med."     Naples,  Sept.  14,  1918,  731. 
JOBERT,  A.  J.     "Arch.  gen.  de  med.,"     Paris,  1838,  iii,  69. 
Kaufmann,  C.     "Deutsche  Zeitschr.  f.  Chir.,"  Bd.  18,  1883,  286. 

KiJTTNER.     "Zent.  f.  Chir.,"  Bd.  44,  1917,  p.  257. 

V.  Langenbeck.     Quoted  by  Binnie:  "Operative  Surgery,"  7th  Ed.,  177. 

Leriche,  R.     "Zent.  f.  Chir.,"  May  i,  1914,  754- 

"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  191 7,  pp.  944,  948. 

MORESTiN,  H.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1915,  832. 
"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1916,  1382. 
"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1917,  845. 

Perthes,  G.     "Zent.  f.  Chir.,"  Bd.  44,  1917,  257. 

PiETRi,  P.     "Restauration  maxillo-faciale."     Paris,  191 7,  105. 

RiCHELOT,  L.  G.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1882,  n.  s.,  viii,  532. 

Sebileau,  p.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  191 7,  947.  . 


SURGERY   OF   THE    CHEEK  6o: 


Tait,  D.     "Surg.,  Gyne.  &  Obst.,"  May,  191 2,  456. 
Tromp,  F.     Zent.  f.  Chir.,"  Bd.  44,  191 7,  1033. 


Facial  Paralysis 

Benders,  E.  C.     "Lancet."    London,  May  24,  1Q13,  1450. 

BuscH.     "Ztschr.  f.  Ohrenh.  u.  f.  d.  Krankh.  d.  Luftvvege,"  1913,  Nrs.  2-3,  175. 
"Beitr.  z.  Anat.,  Physiol.,  Path.  u.  Therap.  d.  Ohres  (etc.),  Berl.,"  1910,  iii. 

Cr.\ndon,  L.  R.  G.     "Med.  &  Surg.  Rep.,  Boston  City  Hospital,"  i6th  series,  1913,  190. 

Eden,  R.     "Beitrage  z.  klin.  Chir.,"  May,  1911,  116. 

GoMOiu,  V.     "Revista  de  Chir  ,"  1908,  No.  9,  385. 
"Lyon  Chir.,"  March,  1913. 

H.\BERLAND,  H.     "Zent.  f.  Chir.,"  Nr.  4,  1916,  74. 
Hildebr.>\xd.     "Zent.  f.  Chir.,"  Xr.  28,  1913,  Supl.  p.  45. 

Jr.\Nti,  A.     "Deut.  Zeitschr.  f.  Chir.,"  Nov.,  1909,  377. 

JiANU,  J.     "Soc  de  Chirurg."     Bucarest,  22,  Dec,  1908. 

JONNESCU,  T.     Quoted  by  A.  Jianu:  "Deut.  Zeitschr.  f.  Chir.,"  Nov.,  1909,  377. 

Lawen,  A.     "Archiv  f.  klin.  Chir."     Berlin,  Xr.  4,  1913,  1083. 
Lexer.     "Beitrage  z.  klin.  Chir.,"  ^lay,  1911,  116. 

MoMBURG.     "Berliner  klin.  Wchnschr.,"  June  13,  1910,  1115. 
Morestin,  H.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1916,  166. 
Murphy,  J.  B.     "Surg.,  Gyne.  &  Obst.,"  April,  1907,  385. 

PlAGET.     "Rev.  hebd.  d.  laryngol.  d'otol.  et  d.  rhinol,"  1913,  xx.xiv,  X'^o.  7. 

Stein,  A.  E.     "Deutscher  Chirurgenkongress."     Berlin,  1913. 
"Zent.  f.  Chir.,"  Xr.  28,  1913,  Supl.  46. 

Zesas,  D.  G.     "Centralbl.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir."     Jena,  Feb.  19,  1914,  141- 


CHAPTER  XXIII 
SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 

GENERAL  CONSIDERATIONS 

Plastic  surgery  of  the  neck,  trunk  and  extremities,  is  certainly  of 
sufficient  importance  to  warrant  more  attention  than  has  hitherto 
been  paid  to  this  branch  of  the  subject.  Thus  far  most  of  the  general 
articles  on  plastic  surgery  make  no  mention  of  this  field,  except  as 
a  source  of  supply  for  flaps  or  grafts  with  which  to  repair  defects  on 
the  face.  It  must  be  remembered,  however,  that  many  deformities 
absolutely  incapacitate  the  patient,  and,  unless  promptly  relieved, 
often  cause  permanent  distortion  of  the  underlying  bony  framework. 
Undoubtedly  among  the  most  difficult  problems  which  confront  the 
plastic  surgeon  are  those  presented  by  the  extraordinarily  varied  con- 
tractures which  occur  in  these  regions. 

The  majority  of  these  deformities  have  been  caused  by  the  con- 
tracture of  scar  following  burns  or  extensive  surface  wounds.  Fortu- 
nately the  scar  is  generally  in  the  skin  and  subcutaneous  tissues,  but 
occasionally  the  deeper  structures  are  implicated.  In  cases  of  long 
standing  contracture  (especially  when  in  flexion)  muscles  and  an- 
terior joint  ligaments  will  be  shortened,  the  growth  of  bone  will  be 
interfered  with,  the  shape  of  articulating  surfaces  will  be  changed,  and 
in  many  instances  the  contour  of  the  bone  itself  will  be  markedly 
distorted.  For  example,  this  may  often  be  seen  when  the  alveolar 
margin  of  the  mandible  is  turned  outward  in  extensive  contracture  of 
the  neck,  and  in  the  bowing  of  the  bones  of  an  extremity  toward  a 
rigid  scar  extending  along  its  full  length.  Not  a  few  of  these  contrac- 
tures are  found  in  children. 

Much  can  be  accomplished  in  burns  or  extensive  loss  of  skin  of 
the  neck,  and  around  joints  to  prevent  contracture  during  the  treat- 
ment of  the  wound  by  early  over-correction  of  the  part,  and  keeping 
it  in  an  over-corrected  position  during  healing.  Healing  should  be 
accelerated  in  every  way,  and  especially  by  skin  grafting.  In  this 
way  contractures  may  to  a  large  extent  be  avoided,  and  if  one  does- 
occur  after  such  precautions  the  relief  of  it  is  a  minor  matter  when 
compared  to  that  of  the  more  extensive  variety. 

606 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


607 


y-dd' 


■^H/^ 


M. 


■  ,     ess.        pa     \£-.. 


--     /     h 


Ifia^' 


Fig.  704. — Arteries  of  the  skin  of  the  from  of  the  trunk  (Manchot). — tl.  Long  thoracic 
artery,  ts.  Superficial  thoracic  artery,  ta.  Thoracic  branch  of  the  acromial-thoracic 
artery,  pm.  Perforating  branches  of  the  internal  mammary  artery,  ptn',  pm",  pm"'. 
Perforating  branches  of  the  intercostal  arteries,  da.  Anterior  circumflex  artery,  pa'. 
Perforating  branches  of  the  anterior  intercostal  arteries,  pi.  Lateral  perforating  branches 
■  f  the  intercostal  and  lumbar  arteries,  ess.  Superior  superficial  epigastric  artery,  est. 
Inferior  superficial  epigastric  artery,  es.  Cutaneous  branches  of  the  superior  epigastric 
artery,  ei.  Cutaneous  branches  of  the  inferior  epigastric  artery,  pra.  Abdominal  branch 
of  the  superficial  external  pudic  artery  (superior),     cfs.  Superficial  circumflex  iliac  artery. 


6o8 


PLASTIC    SURGERY 


Pj(^  705.— Arteries  of  the  skin  of  the  back  {Manchot).—mi-mii.  Median  skin  twigs 
from  the  intercostal  arteries,  m.  Median  skin  twigs  from  the  lumbar  arteries.  Z.  Lateral 
skin  twigs  from  the  intercostal,  lumbar  and  sacral  arteries,  pp.  Posterior  perforatmg 
branches  of  the  intercostal  and  lumbar  arteries,  t.  Dorsal  skin  branches  of  the  transver- 
salis  colli  artery.  55a.  Dorsalis  scapulae  artery,  dp.  Posterior  circumflex  artery.  55. 
Skin  branches  in  the  region  of  the  supraspinous  fossa,  ss'.  Skin  branches  from  the  supra- 
scapular artery.  55".  Skin  branches  from  the  transversaUs  colli  artery,  c.  Skin  branches 
from  the  superficial  cervical  artery. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES      609 


V.i  '1, 


Fig.   706.— Arteries  of  the  skin  of  the  side  of  the  trunk  (Maftchoi).—ts.  Superficial  thoracic 
artery,     pi.  Lateral  perforating  branches  of  the  intercostal  and  lumbar  arteries. 


39 


6lO  PLASTIC    SURGERY 

In  some  instances  a  burn  may  be  so  serious  that  little  is  thought 
of  except  saving  the  life  of  the  patient,  and  even  if  later  the  general 
condition  improves  sufficiently  to  allow  of  over-correction,  it  may  then 
be  impossible. 

Sometimes  the  contracture  is  surrounded  by  skin,  which  is  normal 
or  nearly  so,  but  in  the  great  majority  of  cases  there  is  a  wide  zone 
of  scar  tissue  surrounding  the  contracture,  or  even  the  entire  part  may 
be  covered  with  scar.  In  such  cases  the  problem  of  obtaining  flaps 
of  normal  tissue  becomes  very  difficult. 

Angiomata  and  keloids  may  be  found  in  almost  any  situation, 
and  they  should  be  treated  by  the  methods  previously  described. 

Wide  or  depressed  post-operative  scars,  and  puckered 
DEEPLY  ADHERENT  SCARS,  due  to  old  Suppurative  processes  are  often 
found.  In  certain  instances  the  scar  may  be  excised  and  the  edges 
approximated,  but  recurrence  often  follows  unless  the  continuity  of 
the  line  of  traction  is  broken  by  an  S  or  Z-shaped  incision,  or  by  some 
sort  of  plastic  flap. 

X-RAY  OR  radium  BURNS,    OR  SCARS  FOLLOWING  THESE  BURNS  are 

also  found,  and  great  difficulty  may  be  experienced  in  the  treatment 
on  account  of  the  importance  of  the  underlying  structures  (in  certain 
situations)  and  in  the  depth  of  the  tissue  changes. 

From  the  onset  it  should  be  understood  that  the  correction  of 
contractures  is  very  difficult  and  that  the  process  is  often  long  drawn 
out.  Many  operations  may  be  necessary,  and  careful  preparation  of 
the  patient  and  of  the  prospective  flaps  is  essential. 

In  all  of  these  cases  much  can  be  accomplished  before  operation 
by  systematic  massage  which  should  be  instituted  to  loosen  the  skin 
and  scar  and  improve  the  circulation. 

Methods  of  Treatment. — After  the  contracture  has  been  re- 
lieved, skin  grafts  are  frequently  used  to  cover  the  raw  surfaces; 
sliding  flaps,  without  twisting  the  pedicle,  are  of  great  use  in  certain 
cases  (French  method) ;  pedunculated  flaps  from  neighboring  skin, 
with  more  or  less  twisting  of  the  pedicle,  are  frequently  used  (Indian 
method) ;  flaps  from  distant  parts  are  also  of  great  use  (Italian  method). 

SURGERY  OF  THE  NECK 

Plastic  surgery  of  the  neck  has  to  do  almost  entirely  with  the 
correction  of  deformities  due  to  scar  tissue  following  burns,  operation, 
ulceration  or  trauma.     The  great  majority  of  cases  are  due  to  cicatricial 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES      6ll 

contracture  following  burns  (thermic,  chemical,  .r-ray  or  radium). 
Contractures  of  the  neck  are  often  associated  with  extensive 
scarring  of  the  face,  cicatricial  ectropion  of  the  lips  and  involvement  of 
the  upper  portion  of  the  thorax  and  shoulders.  The  extent  of  the  in- 
volvement of  the  neck  may  vary  considerably.  The  chin  may  be 
drawn  down  on  the  chest,  and  the  head,  neck  and  chest  be  fused  into 
one  solid  mass,  or  there  may  be  all  gradations  of  contracture  between 
this  and  narrow  bands  of  scar  which  prevent  normal  motion. 

The  relief  of  the  neck  contracture  will,  in  many  instances,  greatly 
improve  the  appearance  of  the  face  by  relaxing  tension  on  the  mouth, 
nose  and  eyelids. 

The  scar  tissue  may  be  very  thick  and  dense.  I  have  often  seen 
it  5.  cm.  (2  inches)  thick  in  places,  and  in  these  cases  complete  removal 
of  this  portion  is  essential.  If  any  of  the  scar  is  thin  and  movable, 
it  may  be  advisable  to  utilize  it,  at  least  temporarily,  and  to  remove 
it  later  if  necessary. 

In  cases  of  long  standing  it  may  be  essential  to  divide  the  sternal 
and  clavicular  origins  of  the  sterno-mastoid  muscle  on  one  or  both 
sides,  when  contracture  of  the  muscle  has  taken  place,  and  the  head 
cannot  be  released  after  thorough  division  of  the  scar  tisse. 

Treatment 

Numerous  methods  have  been  advanced  for  the  treatment  of 
contracture  of  the  neck,  the  object  of  all  of  them  being  to  release  the 
chin  and  to  fill  the  defect  thus  made  with  pliable  skin  which  is  as 
nearly  normal  as  possible. 

Gradual  Stretching. — In  certain  cases  much  can  be  accomplished 
by  slow  gradual  stretching  with  some  sort  of  apparatus,  preferably 
elastic  traction,  in  conjunction  with  x-ray,  radium,  massage,  inunc- 
tions, and  other  methods,  but  when  deep  thick  scar  is  present  these 
methods  are  useless,  and  we  must  resort  to  more  radical  procedures. 

Division  of  Scar  Tissue  (Dupuytren,  Earle,  James,  and  others). — 
The  earliest  operative  method  of  treatment  was  the  division  (either 
multiple  or  single)  of  the  contracting  bands  down  to  normal  tissue, 
and  long  continued  over-correction  of  the  head.  If  bands  subse- 
quently formed,  they  were  divided  as  often  as  necessary,  but  this 
method  was  tedious  and  the  results  were  generally  unsatisfactory. 

Pedunculated  flaps  of  the  scar  tissue  have  been  shifted  in  various 
ways  to  relieve  the  contracture,  and  the  head  placed  in  an  over-corrected 


6l2 


PLASTIC    SURGERY 


position.  But  almost  invariably  sloughing  of  the  flap  occurs  and  re- 
contracture  frequently  follows.  Unless  the  scar  is  thin  and  very  mov- 
able, it  is  useless  to  attempt  to  utilize  it.  On  several  occasions  I  have 
been  able  to  shift  successfully  a  scar  of  this  type  in  the  form  of  a  wide 
double-pedicled  bridge  flap,  but  when  normal  tissue  is  available  one 
should  never  employ  flaps  of  scar  tissue. 

Excision    (partial  or  complete)    of  the   contracting  scar  is   the 
rational  method,  the  defect  being  covered  with  skin  grafts  or  with  a 


Fig.  707.  Pig.   708. 

Pig.  707. — Method  of  utilizing  a  flap  from  the  back  for  the  relief  of  a  neck  defect  {Ber- 
ger). — The  dark  lines  outline  the  flap  A  with  its  pedicle  on  the  neck  at  the  margin  of  the 
defect.  This  flap  can  only  be  used  to  cover  one-half  of  the  neck,  or  possibly  a  little  more. 
The  dotted  lines  mark  out  the  flap  B,  which  is  brought  forward  on  the  other  side  to  complete 
the  collar  of  normal  skin,  if  the  defect  covers  both  sides.  The  raw  surface  on  the  back 
should  be  grafted. 

Pig.  708. — The  use  of  flaps  from  the  arms  for  the  relief  of  contracture  of  the  neck. — 
The  free  ends  of  the  flaps  A  and  A'  raised  from  the  front  of  the  arms  and  shoulders  are 
sutured  in  the  midline,  after  dividing  the  contracting  scar.  The  raw  surfaces  B  and  B' 
should  be  skin  grafted.     Croft's  plan  may  also  be  used  in  this  type  of  flap. 


pedunculated  flap.  Flaps  may  be  taken  from  the  shoulder,  the  arm, 
the  chest  and  the  back,  and  should  consist  of  the  skin  and  subcutaneous 
fat. 

Partial  Gradual  Excision.— I  have  often  excised  portions  of  the 
edge  of  a  thickened  scar  on  the  neck  and  shifted  up  the  adjacent  normal 
skin  to  fill  the  gap,  this  process  being  continued  after  the  skin  had 
stretched,  until  finally  the  entire  scar  was  removed.  This  may  also  be 
done  by  partial  excision  in  any  selected  portion  of  the  scar  tissue, 
and    the  edges  may  be  closed  after  undercutting.     This  process  is 


J 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


613 


continued  until  the  greater  part  of  the  scar  is  removed,  and  then  if  the 
necessity  still  exists,  the  desired  plastic  operation  may  be  performed. 

The  Use  of  Skin  Grafts.- — In  very  extensive  contractures  complete 
excision  of  the  thickened  keloid-like  scar  may  not  be  practicable  at 
one  operation.  In  these  cases  the  scar  may  be  removed  at  the  margin, 
or  from  the  central  portion.  The  head  should  then  be  over-corrected 
as  far  as  possible,  and  the  gap  filled  with  skin  grafts  (Ollier-Thiersch, 
or  preferably  of  whole-thickness)  if  a  pedunculated  flap  is  not  available. 

In  using  grafts  on  the  neck  those  of  whole-thickness  are  the  best, 
on   account    of    their    subsequent   flexibility    and    ability   to   stretch. 


/"^ 


'I  //  ^"i 


Fig.  709. — Method  of  utilizing  a  flap  from  the  arm  for  the  relief  of  a  neck  contracture 
(v.  Hacker). — i.  Contracture  of  the  neck  following  a  burn.  2.  Pedunculated  flap  from  the 
arm  with  its  base  near  the  shoulder.  The  contracture  has  been  relieved,  and  the  flap  is 
turned  back  and  its  free  end  A  has  been  sutured  into  the  posterior  edge  of  the  defect.  The 
upper  and  lower  edges  of  this  portion  are  also  sutured.  Later  the  pedicle  is  cut  and  the 
ends  are  fitted  in.     The  defect  B  on  the  arm  should  be  grafted. 

Ollier-Thiersch  grafts  are  often  used,  but  are  not  so  satisfactory  as 
whole-thickness  grafts  for  this  purpose.  Small  deep  grafts  should  be 
used  only  as  a  temporary  measure  to  hasten  cicatrization,  although  the 
healed  surface  is  later  to  be  removed. 

The  Use  of  Pedunculated  F.aps.^ Divide  the  scar  transversely 
through  its  center  from  normal  skin  to  normal  skin,  and  over-correct 
the  head.  Trim  ofl"  as  much  of  the  scar  from  the  edges  as  may  be 
desired,  and  implant  a  flap  which  is  a  little  wider  and  longer  than  the 
defect.  If  the  defect  is  on  one  side  only,  or  in  the  middle,  one  flap  may 
be  sufficient,  but  if  it  extends  well  around  the  neck,  a  flap  must  be 
obtained  from  each  side. 


6i4 


PLASTIC    SURGERY 


If  the  neck  only  is  implicated  and  the  shoulders  and  thorax  are 
free,  the  problem  is  more  or  less  simple,  because  flaps  may  be  obtained 
from  these  regions.  But  in  many  cases  it  is  a  difficult  matter  to  obtain 
flaps  from  adjacent  skin  on  account  of  scar  involvement,  and  we  have 
to  obtain  them  from  distant  parts  by  double  or  single  transfer. 

When  a  long  flap  is  used,  it  is  safer  to  raise  it  from  its  bed,  but 
leave  it  attached  at  its  extremities,  and  gradually  divide  the  free  end 
from  its  attachment.  In  this  way  we  may  succeed  with  a  flap  which  if 
raised  and  at  once  shifted,  would  slough  for  at  least  one-third  of  its 
length. 


Fig.  710.  Pig.  711. 

Pig.  710. — The  relief  of  a  contracture  of  the  neck  with  a  flap  from  the  shoulder  and 
deltoid  region  (Miitter). — The  flap  A  is  shown  in  position  after  the  neck  contracture  has 
been  relieved.      The  area  B,  from  which  the  flap  was  raised,  should  be  grafted. 

Pig.  711. — The  relief  of  a  contracture  of  the  neck  with  a  flap  from  the  chest  wall 
(Morestin). — The  contracture  has  been  relieved  and  the  large  flap  shifted  up  from  the  chest 
wall  to  fill  the  defect. 


Tracheal  Defects 

Occasionally  the  plastic  surgeon  is  called  upon  to  repair  a  tracheal  I 
fistula,  or  even  to  reconstruct  a  portion  of  the  trachea  which  may  have 
been  destroyed  by  trauma,  operation,  ulceration,  or  a  burn. 

In  a  recent  paper  on  the  experimental  transplantation  of  the  trachea 
Burket  found  that  the  normal  trachea  was  sterile  from  the  larynx  to  the 
hilus  of  the  lung.  He  was  able  completely  to  remove  and  replace  in  the 
same  dog  successfully  as  many  as  eight  tracheal  rings,  but  his  iso- 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


615 


Fig.  712. — Contracture  of  the  chin,  neck  and  chest  following  a  burn. — i.  The  condition 
of  the  patient  when  he  came  under  my  care.  He  had  been  operated  on  several  times  before, 
and  nearly  all  of  the  available  usable  material  had  been  exhausted.  Note  the  scar  on  the 
face,  neck,  chest,  shoulders  and  arms.  2.  Taken  eighteen  months  after  the  first  photo- 
graph. Note  the  improvement  in  the  condition  of  the  cheek  and  chin,  and  the  partial 
release  of  the  arms. 


Fig.  713. — Contracture  of  the  chin,  neck  and  chest  continued. —  r  and  2.  The  condition 
three  years  later,  after  several  other  plastic  operations.  The  chin  is  released  and  with 
minor  procedures  can  be  much  improved.  The  arms  can  be  raised  over  the  head  and  are 
functionally  perfect.  Note  the  newly  formed  axillas  and  compare  with  2,  Fig.  712.  Cases 
of  this  type  are  difficult  to  deal  with  and  good  results  are  dependent  on  the  perfect  coopera- 
tion of  the  patient  and  the  parents  with  the  surgeon. 


6i6 


PLASTIC    SURGERY 


transplants  were  not  so  successful.  This  work  may  be  of  great  clinical 
use  in  certain  cases,  and  is  well  worth  bearing  in  mind. 

Treatment. — It  is  usually  necessary  to  perform  a  tracheotomy 
(preferably  transverse)  below  the  defect  before  closing  any  gap  in  the 
trachea.     This  precaution  may  save  much  worry  and  discomfort. 

Occasionally,  when  the  defect  is  very  small,  the  edges  may  be 
freshened  and  sutured  together  (Dupuytren,  Le  Fort,  Jacobson).  In 
other  cases  the  tissue  on  each  side  of  the  defect  may  be  raised  and  turned 
inward  and  sutured,  so  that  the  epithelial  surface  is  toward  the  lumen 


Fig.  714. — Contracture  of  the  neck  following  a  burn. — i.  Note  the  practical  elimina- 
tion of  the  neck  on  right  side.  Also  the  scars  on  the  neck,  chest,  arm  and  back.  2.  The 
relief  of  the  contractiire  by  the  use  of  a  pedunculated  flap  from  the  shoulder  and  back. 
Taken   two    weeks   after   operation. 

of  the  tube  (Berger).  The  raw  area  is  then  covered  by  sliding  in 
adjacent  skin,  or  by  any  other  selected  method. 

Complete  excision  (Kiister,  1885)  of  the  defective  portion  of  the 
trachea  (from  2.  to  4.  cvs\.  —  %  to  i^^  inches)  and  successful  suture  of 
the  ends  has  been  done,  but  on  account  of  the  dangers  of  infection  and 
inability  to  extend  the  neck  because  of  the  shortening,  this  procedure 
is  not  always  advisable.  The  amount  which  can  be  resected  depends 
largely  on  the  length  of  the  neck,  and  the  distance  between  the  rings. 

Silver  wire  mesh  (Landerer,  Grosse)  has  been  shaped  and  placed  over 
the  defect,  and  the  soft  parts  closed  over  it;  rubber  tubes  and  other 
inorganic  substances  have  been  used,  but  these  buried  prostheses 
are  to  be  advised  no  more  in  this  region  than  elsewhere. 


SURGERY  OF  THE  XECK,  TRUNK,  AND  EXTREMITIES      617 

Pedunculated  flaps  of  skin  have  been  shifted  over  the  defect 
(Reid  and  others),  but  unless  the  gap  is  small,  the  lumen  of  the  trachea 
may  be  blocked.  It  is  better  to  turn  in  a  flap  with  epithelium  toward 
the  lumen  to  fill  the  gap  and  later  to  cover  this  with  another  flap 
(Abbe  and  others).  To  avoid  sagging  of  the  skin,  flaps  containing  a 
supporting  substance  are  to  be  preferred.  Pedunculated  flaps  containing 
undetached  bone  from  the  sternum  (Schimmelbusch)  or  clavicle 
(Photiades,  Lardy)  have  been  used.  Chiari  uses  Gluck's  technic.  He 
shifts  in  a  quadrangular  flap  from  one  side  of  the  neck  to  form  the 
posterior  wall  of  the  trachea.  After  this  has  healed  a  flap  from  the  other 
side  is  sutured,  skin  surface  inward,  to  form  the  anterior  wall,  and  over 
this  is  placed  a  flap  containing  a  thin  layer  of  bone  from  the  sternum. 
Konig  used  a  pedunculated  flap  of  skin,  with  cartilage  attached,  from 
the  thyroid  cartilage. 

Free  bone  has  also  been  implanted  beneath  the  skin  and  has  later 
been  shifted  with  the  skin  flap  to  fill  the  gap,  but  this  material  will 
eventually  be  absorbed  and  is  therefore  not  reliable. 

None  of  these  methods  can  compare  with  the  use  of  cartilaginous 
rib  (von  Mangoldt,  Oct.  5,  1897)  implanted  beneath  the  skin,  to  be 
shifted  later.  I  have  found  it  advantageous,  when  implanting 
cartilage  into  the  skin  of  the  neck  to  reform  the  trachea  (if  the  gap 
is  of  any  length)  to  make  narrow  notches  transversely  about  i.  cm. 
(^5  inch)  apart,  down  to  but  not  through,  the  perichondrium.  This 
will  allow  a  certain  amount  of  flexibility  to  the  newly  formed  trachea. 
In  a  long  wide  defect  a  central  longitudinal  notch  may  also  be  made 
in  a  wide  piece  of  cartilage,  to  allow  for  slight  lateral  bending  to  form 
the  wall  of  the  trachea.  I  have  found  it  a  good  procedure  in  large 
defects  to  implant  cartilage  parallel  to  the  defect,  and  fairly  close  to  it  on 
each  side.  Then,  after  a  number  of  months,  I  raise  a  rectangular  lateral 
flap  on  each  side  with  the  pedicle  close  to  the  margin  of  the  defect, 
and  turn  over  these  flaps,  including  the  cartilage,  skin  side  inward,  and 
suture  them  in  the  midline.  The  raw  surface  of  the  prepared  flaps 
and  the  defects  from  which  they  have  been  raised,  are  covered  with  a 
pedunculated  flap  of  skin.  If  the  defect  is  large,  it  is  better  to  wait 
until  the  new  tube  is  completed  before  connecting  it  with  the  trachea 
above  and  below.  If  the  thyroid  cartilage  is  destroyed,  an  effort  should 
be  made  to  shape  the  cartilaginous  rib  which  is  to  be  used  in  repairing  it, 
before  it  is  implanted.  My  experience  has  been  that  it  is  difficult  to 
maintain  the  cartilage  in  the  V-shape,  but  this  form  may  be  again  regained 
if  the  cartilage  ends  can  be  secured  (at  the  time  of  final  transplantation) 


6i8 


PLASTIC    SURGERY 


I  2 

Pig.  715. — Method  of  reconstructing  a  gap  in  the  trachea. — i.  The  dark  lines  indicate 
the  incisions  through  which  the  pieces  of  cartilaginous  rib  were  implanted  parallel  to  the 
defect.  The  dotted  lines  indicate  the  location  of  the  notched  cartilage.  The  perichon- 
drium is  outward.  The  inserts  show  the  method  of  notching  the  cartilage  in  order  to  give 
it  more  flexibility.  More  than  one  piece  of  cartilage  may  be  implanted  on  each  side  if 
necessary.  2.  The  dark  lines  indicate  the  flaps  with  their  bases  toward  the  midline.  The 
insert  shows  the  flap  turned  in  and  sutured,  the  edge  AB  to  the  edge  A'B'.  The  raw  sur- 
face may  be  grafted,  but  a  pedunculated  flap  is  preferable. 


I  2 

Fig.   716. — Method  of  closing  a  large  chest  defect  by  extensive  undercutting  and  shift-  i 
ing    the   surrounding   skin   (Morestin). — i.   The   shaded   area  indicates   the   defect.     The 
dotted  line  shows  the  extent  of  the  undercutting  necessary  in  order  to  close  the  skin  over 
the  defect.      2.   The  edges  sutured  and  the  wound  covered. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


619 


to  the  remains  of  the  thyroid  cartilage.  In  the  repair  of  large  gaps  in 
the  trachea  the  operations  are  multiple,  and  the  results  are  only  fair. 
In  small  gaps  involving  only  a  portion  of  the  tracheal  rings,  results  are 
much  better  (Fig.  715). 

In  tracheal  fistulae  in  which  not  more  than  one-third  of  the  circum- 
ference of  one  or  two  of  the  cartilage  rings  has  been  destroyed,  I  have 
been  able,  experimentally,  to  close  the  defect  with  a  graft  of  fascia  lata 


Fig.  717. — Pigmented  mole  of  the  chest  wall.  Congenital.  This  patient  before  com- 
ing under  my  care  had  been  treated  with  carbon  dioxide  snow,  and  an  attempt  had  been 
made  to  lower  the  growth  into  the  axilla  where  it  would  not  show.  The  only  method  of 
treatment  which  promised  a  satisfactory  result  was  partial  gradual  excision. — i.  The 
result  of  the  first  operation,  in  which  the  greater  part  of  the  pigmented  area  was  removed, 
and  the  edges  were  closed.  2.  Result  of  the  second  excision.  Further  excisions  will  be 
necessary,  but  in  time  the  entire  area  will  be  removed  without  distortion  of  the  part,  and 
with  the  scar  at  the  pectoral  margin. 

which  is  snugly  sutured  over  it.  ^  Later  the  microscopic  sections 
showed  that  the  mucous  membrane  covered  this  graft  and  was  continu- 
ous with  the  lining  of  the  rest  of  the  trachea.  The  method  is  simple, 
and  unless  the  gap  is  too  wide  is  well  worth  trying. 

SURGERY    OF    THE    TRUNK 

Plastic  surgery  of  the  trunk  for  the  most  part  deals  with  the  relief  of 
contractures,  and  the  covering  of  the  defects  (due  to  operation,  injur}^ 
or  ulceration)  with  skin. 

^Davis,  J.  S.,  "Johns  Hopkins  Hospital  Bull./'  October,  igii,  372. 


620 


PLASTIC    SURGERY 


With  the  exception  of  a  few  words  on  the  treatment  of  hernia 
of  the  lung  through  the  thoracic  wall,  the  surgery  of  the  trunk  will  be 
dealt  with  here  only  so  far  as  it  concerns  the  repair  of  surface  defects 
and  contractures. 

Usually  extensive  contractions  of  the  neck  and  axilla  are  closely 
associated  with  those  of  the  trunk.  Many  small  defects  may  be  closed 
by  the  plastic  methods  previously  described.  I  have  seen  extensive 
contracted  scars  involving  the  entire  front  or  side  of  the  chest  and 


Fig.  718. — Method  of  reducing  the  size  of  a  granulating  wound  by  elastic  traction. — 
The  wound  pictured  was  due  to  the  excision  of  the  breast  for  a  severe  infection.  Note 
the  muslin  bands,  to  which  the  hooks  are  sewed,  pasted  to  the  skin.  Ordinary  small 
elastic  bands  are  placed  over  these  hooks  and  they  exert  continuous  elastic  traction  on  the 
skin  edges.  In  this  way  the  size  of  the  wound  may  be  considerably  reduced  in  a  compara- 
tively short  time. 


abdomen,  and  the  upper  portion  of  the  thigh.  To  avoid  permanent 
asymmetry  it  is  essential  to  break  the  continuity  of  such  scars  in  several 
places  in  order  to  straighten  the  body  (complete  excision  being  out  of 
the  question).  This  should  be  done  as  early  as  possible  and  can  be 
accomplished  by  means  of  skin  grafts  alone  (preferably  of  whole- 
thickness),  or  with  pedunculated  flaps  shifted  in  from  any  available 
normal  skin.  Sometimes  a  combination  of  these  methods  is  advanta- 
geous.    The  skin  of  the  trunk  is  a  very  useful  source  of  supply  in  obtain- 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


62I 


ing  pedunculated  flaps  for  use  on  the  neck  or  upper  extremity.  By 
a  double  transfer  these  flaps  may  be  carried  to  the  face,  or  to  any  other 
desired  situation. 

Morestin  has  demonstrated  that  very  large  areas  of  skin  may  be 
shifted  by  undercutting,  and  he  undermines  extensive  areas,  as  much 
as  25.  to  30.  cm.  (10  to  12  inches)  when  necessary,  in  order  to  free  the 
skin  sufficiently.  I  have  frequently  used  this  method  and  find  it  a 
most  useful  procedure. 


Fig.  719. — A'-ray  burn  of  the  chest.  Duration  four  years. — The  breast  had  been 
amputated  for  carcinoma  eight  years  before  admission,  and  after  amputation  A'-ray  treat- 
ments were  given  very  frequently  for  the  succeeding  four  years.  A  burn  resulted  which 
involves  the  chest,  shoulder,  upper  arm  and  axilla.  During  the  four  years  preceding  ad- 
mission no  further  A'-ray  treatment  was  given.  The  area  which  can  be  seen  in  the  photo- 
graph is  a  typical  A'-ray  burn  which  heals  and  breaks  down.  The  skin  and  tissues  are 
hard  and  adherent.  Telangiectatic  patches  are  everywhere  and  the  entire  area  is  exqui- 
sitely tender.  The  area  was  completely  excised  and  the  wound  was  grafted  with  small 
deep  grafts,  after  the  granulations  were  in  proper  condition. 

The  Closure  of  Defects  After  Operation  for  Carcinoma  of  the 
Breast. — The  feeling  of  all  of  us  who  have  been  connected  with  Dr. 
Halsted's  Clinic  at  the  Johns  Hopkins  Hospital  is  that  none  of  the  plas- 
tic closures  so  elaborately  described  in  certain  articles  on  carcinoma 
of  the  breast  are  necessary,  and  in  fact  are  often  undesirable  after 
the  radical  breast  amputation.  The  best  results  in  breast  amputa- 
tions for  malignant  disease  have  undoubtedly  been  obtained  by  the 
operators  who  remove  the  tumor  with  a  very  wide  margin  of  skin. 


622 


PLASTIC    SURGERY 


I  2 

Pig.  720. — Operation  for  closing  a  chest  defect  (Quenu  and  Rohineau). — i.  The  defect 
is  indicated  by  the  shaded  area.  The  flap,  by  the  dark  lines.  2.  The  flap  A  shifted  upward 
and  sutured  into  the  defect.  The  curved  dotted  line  indicates  the  extent  of  the  undercut- 
ting required. 


Fig.  721. — -Method  of  closing  a  chest  defect  with  a  flap  from  the  abdominal  wall 
(Elsberg). — i.  The  shaded  area  indicates  the  defect.  The  dark  lines  indicate  the  outHnes 
of  the  flap  of  skin  and  fat  raised  from  the  abdominal  wall.  2.  The  flap  shifted  upward 
and  sutured. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


623 


If  the  surgeon  has  in  mind  immediate  closure  of  the  edges  he  is  apt  to 
skimp  on  the  amount  of  skin  which  he  removes.  It  is  unquestionably- 
better  to  remove  too  much  skin  than  too  little  in  these  cases,  because 


Fig.  722. — Method  of  closing  a  chest  defect  with  a  flap  from  the  abdominal  wall 
(Weichert) . — i.  Shaded  area  indicates  the  defect.  The  dark  line  below  marks  out  the  flap 
A.     2.  The  flap  A  raised  and  sutured  into  position.     The  other  skin  defects  are  also  sutured. 


Fig.  723. — Operation  for  closing  a  chest  defect,  by  utilizing  the  other  breast  (Legtieu). — 
I.  The  dotted  area  indicates  the  defect.  The  dark  lines  indicate  incisions  outlining  the 
flap.     2.   The  flap  shifted  toward  the  defect  and  sutured. 

the  defect  however  large,  can  be  immediately  grafted  with  Ollier- 
Thiersch  grafts,  which  are  those  usually  selected. 

I  shall  describe  here  Dr.  Halsted's  latest  method  of  forming  an 
axilla  after  breast  amputation,  as  it  may  be  useful  in  dealing  with  other 


624 


PLASTIC    SURGERY 


defects.  It  is  applicable,  however,  only  where  the  surrounding  skin 
is  normal.  For  removing  the  breast  Dr.  Halsted  uses  a  circular  inci- 
sion surrounding  the  tumor,  and  extending  from  this  a  vertical  incision 
toward  the  clavicle,  if  necessary,  and  another  one  below  which 
aids  in  the  dissection  of  the  axilla.  To  quote  his  words:  "The 
skin  of  the  outer  flap  between  the  two  vertical  incisions  is  utilized 
primarily  to  cover  completely,  without  any  tension  whatever  and  re- 
dundantly, the  vessels  of  the  axilla.  The  edge  of  this  flap  is  stitched 
by  interrupted  buried  sutures  of  very  fine  silk  to  the  fascia  just  below 
the  first  rib  in  such  a  way  that  the  skin  partly  envelopes  the  large 
vessels.     Then,  along  the  entire  circumference  of  the  wound,  the  free 


Fig.  724. — Legueu's  operation,  continued. — i.  After  stretching  has  taken  place  the  flap 
is  shifted  still  further.  Note  the  notches  made  above  and  below  to  facilitate  stretching. 
2.   The  flap  in  position.     This  draws  the  normal  breast  to  the  midline. 

edge  of  the  skin  is  sutured  to  the  underlying  structures  of  the  chest 
wall,  the  wound  being  made  as  small  as  desirable  in  the  process  of 
closure,  and  tension  of  the  upper  or  axillary  part  of  the  outer  flap 
assiduously  avoided.  Considerable  traction  may,  however,  be  exer- 
cised on  the  mesial  flap  and  on  the  lower  portion  of  the  outer  flap. 
Whatever  the  size  and  shape  of  the  grafted  defect,  it  should  usually 
extend  to  the  top  of  the  axillary  fornix.  Thus  the  thoracic  or  inner 
wall  of  the  apex  of  the  axilla  is  always  lined  with  skin  grafts." 

Skin  grafts  seem   to   offer  a  definite  obstacle  to  the  growth  of 
metastases,  and  it  is  very  rare,  if  ever,  that  the  grafted  area  is  invaded. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


625 


If  metastases  occur  in  the  (leejK'r  tissues  beneath  the  graft,  they  can  be 
seen  and  attended  to. 

The  operation  of  shifting  the  other  breast  over  to  cover  the  defect 
it)llowing  breast  amputation  is  not  only  unnecessarily  extensive,  but 
also  prevents  the  early  recognition  of  any  metastases,  because  of  its 
thickness. 

Methods  of  Closing  Defects  on  the  Trunk.— Many  methods  have 
been  devised  for  closing  the  defect  after  amputation  of  the  breast, 
and  the  principles  involved  in  the  majority  of  these  may  be  applied  in 
filling  defects  anywhere  on  the  trunk.     My  belief  is  that  plastic  opera- 


FiG.  725. — Method  of  closing  a  chest  defect  by  means  of  a  flap  including  the  other  breast 
{Weichert). — i.  The  defect  is  indicated  by  the  shaded  area.  The  dark  line  indicates  the 
incision  marking  out  the  flap  A.     2.  The  flap  A  in  position  and  all  wounds  closed. 

tions  are  not  desirable  in  covering  defects  left  by  the  radical  opera- 
tion for  carcinoma  of  the  breast,  such  as  shifting  over  the  other  breast, 
but  that  they  may  be  used  with  great  advantage  in  covering  defects 
from  other  causes.  Unfortunately,  all  of  these  flap  operations  on 
the  trunk  are  based  on  the  utilization  of  skin  which  is  not  infiltrated 
with  scar,  and  a  glance  at  the  diagrams  will  show  the  impossibility 
of  carrying  out  successfully  these  methods  unless  the  skin  is  normal. 
For  this  reason  in  many  instances  we  must  depend  on  skin  grafts. 
In  large  defects  the  Ollier-Thiersch  variety  is  that  usually  employed 
on  the  trunk,  but  when  the  defect  is  smaller,  whole-thickness  grafts 
give  good  results.  I  often  use  small  deep  grafts  on  granulating  sur- 
faces on  the  trunk,  and  find  them  very  satisfactory. 

The  French  method  of  gliding  flaps  is  that  most  frequently  em- 

40 


626 


PLASTIC    SURGERY 


Fig.  726. — Operation  for  closing  a  chest  defect  (Roux,  Beck). — The  shaded  area  in- 
dicates the  defect.  The  three  dark  Hnes  show  the  incisions  made  in  Roux's  operation. 
The  dotted  line  indicates  the  additional  incision  made  in  Beck's  operation.  The  flaps  are 
shifted  toward  each  other  and  are  sutured. 


Z  2 

Fig.  727. — Operation  for  closing  a  breast  defect  (Ombredanne). — i.  The  dotted  area 
indicates  the  defect.  The  dark  lines  the  incisions  outlining  the  fiap.  The  flap  ABCD  is 
raised  and  half  turned  on  itself,  the  point  B  being  brought  to  the  point  E.  2.  The  flap 
sutured  into  position  and  all  skin  defects  sutured. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


627 


I  2 

Fig.  728. — Operation  for  closing  a  large  chest  defect  (Shrady). —  i.  The  shaded  area 
indicates  the  defect.  The  dotted  lines  indicate  the  incisions  made  in  forming  the  flaps. 
2.   The  flaps  shifted  and  the  edges  sutured. 


I  2 

Pig.  729. — Modified  Tansini's  method  of  closing  a  chest  defect. — i.  The  shaded  area 
B  indicates  the  defect.  The  dark  lines  mark  the  outline  of  the  flap  A.  2.  The  flap  A  is 
jumped  over  the  bridge  of  skin  between  and  sutured  into  the  defect.  The  area  from  which 
the  flap  is  raised  is  either  sutured  or  grafted.  For  our  purpose  only  skin  and  subcutaneous 
fat  is  included  in  the  flap.  In  the  original  operation  the  flap  contained  the  latissimus 
dorsi,  the  teres  major  and  a  portion  of  the  infraspinatus  muscles. 


628 


PLASTIC    SURGERY 


ployed,  but  flaps  from  neighboring  skin  with  twisting  of  the  pedicles 
are  also  very  useful.  A  pedunculated  flap  from  the  arm  may  be 
utilized  to  fill  a  trunk  defect,  but  this  is  not  often  a  desirable  procedure. 
In  shifting  flaps  to  fill  defects  we  have  to  choose  from  several 
varieties.     A  single  flap  from  below  and  on  the  same  side  fQuenu  and 


Fig.  730. — X-ray  burn  of  the  abdominal  wall. 
extent  of  the  burn  and  its  typical  appearance.  2 
and  after  granulations  have  formed. 


Duration  fifteen  years. — i.    Note  the 
The  area  after  excision  of  the  burn 


Robineau,  Elsberg  and  others) ;  a  single  flap  from  below  and  on  the 
opposite  side  fWeichert  and  others) ;  a  single  lateral  flap  from  the 
opposite  side  (Legueu  and  others) ;  a  single  external  dorsal  flap 
fTansini);  double  vertical  flaps  (Roux  and  Beck);  four  flaps,  two 
above  and  two  below,  with  lateral  pedicles  (Shrady). 


i  Fig.  731. — X-ray  burn  of  the  abdominal  wall,  continued. — i.  The  use  of  a  wire  cage 
in  protecting  the  grafted  area.  2.  Taken  three  months  after  grafting  with  small  deep  grafts. 
There  has  been  no  further  trouble  during  the  two  years  since  operation. 


Adhesion  Between  the  Arm  and  Thoracic  Wall 

This  condition  often  follows  extensive  burns  of  the  arm  and  chest. 
The  web  may  be  quite  thin  and  lax,  allowing  a  considerable  amount  of 


SURGERY  OF  THE  XECK,  TRUNK.  AND  EXTREMITIES 


629 


2  3  4 

Fig.  732. — Ulcer  of  the  buttock  and  side  due  to  a  burn.  Duration  three  months.- — i  and 
2  show  the  extent  of  the  burn.  The  whitish  patches  in  i  are  grafts  which  were  applied 
before  the  patient  came  under  my  care,  and  which  are  nearly  covered  with  exuberant 
granulations.  The  granulations  were  trimmed  off,  the  grafts  previously  placed  were 
carefully  preserved,  and  the  rest  of  the  area  grafted  with  small  deep  grafts.  3.  Healing 
soon  followed.  Note  the  larger  grafts  which  had  been  buried  in  the  granulation  tissue  and 
which  spread  promptly  when  given  a  chance,  and  the  spaces  between  filled  with  small 
deep  grafts.  The  photograph  was  taken  six  weeks  after  admission.  4.  Photograph  taken 
one  year  later.      Note  the  smooth  movable  healing. 


Fig.  733. — Method  of  closing  an  abdominal  defect  by  extensive  mobilization  of  the 
surrounding  skin  (Morestin). — The  shaded  area  indicates  the  defect  after  excision  of  the 
growth.  The  dotted  line  shows  the  area  of  skin  mobilized  by  undercutting  before  closure 
was  possible. 


630  PLASTIC    SURGERY 

motion,  but  in  other  cases  it  may  be  as  thick  as  the  arm  and  absolutely 
rigid.  When  the  arm  has  been  closely  adherent  to  the  chest  wall  for 
some  time,  care  should  be  taken  when  it  is  released  to  raise  it  slowly, 
in  order  to  stretch  the  vessels  and  nerves  gradually. 

Treatment 

Division  and  Suture  of  Edges. — The  natural  tendency  for  the 
inexperienced  operator  is  simply  to  divide  the  web,  abduct  the  arm  and 
suture  the  edges.  For  thin  incomplete  webs  this  may  be  accomplished 
with  S  or  Z-shaped  incisions,  with  some  success,  but  recurrence  will 
invariably  follow  such  a  procedure  unless  it  is  done  with  more  than 
ordinary  skill. 

Formation  of  Epithelial  Lined  Fistula.  — Along  the  same  line  is  the 
relief  of  these  contractures  by  first  making  a  fistula  high  up  toward 
the  axilla  and  allowing  the  edges  to  heal,  as  was  done  in  old  operations 
for  syndactylism  and  for  the  formation  of  oral  commissures.  Then, 
after  healing  has  taken  place  to  divide  the  web.  This  is  a  poor 
surgical  procedure  and  a  good  axilla  can  never  be  formed  by  this 
method  alone. 

Reconstruction  of  the  Axilla. — The  formation  of  a  high,  well  lined 
axilla  is  the  key  to  the  satisfactory  relief  of  these  conditions,  and  this 
may  be  done  in  several  ways.  The  choice  of  operation  depends  largely 
on  the  character  of  the  web,  and  on  the  condition  of  the  skin  on  the 
arm  and  trunk  immediately  adjacent  to  the  contracture.  If  the  skin 
is  normal,  or  only  superficially  scarred,  it  may  be  used  for  flaps.  But 
when  scar  is  wide-spread  and  deep,  the  problem  is  much  more  com- 
pHcated,  and  flaps  must  be  shifted  in  from  parts  at  a  distance,  or  skin 
grafts  must  be  used. 

After  the  chest  wall  and  axilla,  or  the  arm  and  axilla,  are  covered 
with  grafts  ('preferably  of  the  Ollier-Thiersch  variety)  the  danger  of 
adhesion  is  over,  and  if  any  secondary  contracture  occurs,  or  there  is 
limitation  of  motion,  after  skin  grafting,  it  is  comparatively  easy  to 
correct  it. 

Some  of  the  operations  already  mentioned  for  covering  chest  defects 
after  complete  removal  of  the  breast,  modified  to  suit  conditions,  may 
be  utilized  for  the  formation  of  the  axilla  after  the  division  and  exci- 
sion of  the  web,  especially  those  of  Halsted,  Tansini,  and  Elsberg. 
But  all  of  these  are  based  on  the  use  of  normal  skin  flaps  and,  if  the 
skin  is  infiltrated  with  scar,  they  cannot  be  employed. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


631 


When  the  axilla  is  obliterated,  and  the  upper  portion  of  the  arm  is 
bound  to  the  chest  wall,  numerous  methods  of  utilizing  flaps  to  form 
the  axilla  have  been  described,  all  of  them  bein?  based  on  the  supposi- 
tion that  the  surrounding  skin  is  normal,  a  condition  seldom  found  in 
actual  practice. 

Jobert's  Operation. — Jobert  raises  a  transverse  flap,  from  the  chest, 
of  sufficient  length  and  breadth  with  its  pedicle  above  the  axillary 
fold,  and  turns  it  backward  to  line  the  axilla. 

Chaput  uses  a  vertical  flap  from  the  skin  of  the  breast  and  chest 
with  its  pedicle  above,  and  on  the  level  with  the  axilla.     This  flap*is 


Fig.   734.  Fig.   735.  Fig.   736. 

Operations  for  the  restoration  of  the  axilla  by  the  use  of  pedunculated  flaps. 
Fig.   734. — Jobert's  operation. — The    dark   line  indicates  the  outline  of  the  flap  from 
the  chest  and  also  the  line  of  division  of  the  web. 

Pig.   735. — Chaput's  operation. — The  flap  is  raised  from  the  chest  wall  with  its  pedicle 
above. 

Fig.   736. — Berger's  operation. — The  flap  is  raised  from  the  scapular  region  with  its 
pedicle  above. 

turned  back  to  form  the  axilla.     Berger  raises  a  somewhat  similar  flap 
from  the  skin  of  the  back  for  the  same  purpose  (Fig.  734-736). 

In  more  extensive  cases  the  procedure  of  Defontaine  may  be  useful. 
He  makes  a  vertical  Y-shaped  incision  on  front  and  back,  the  arms  of 
which  begin  in  the  normal  skin  just  above  the  level  of  the  axilla,  and 
meet  at  the  junction  of  the  upper  and  middle  thirds  of  the  web. 
The  V-shaped  flaps  of  skin  included  between  these  incisions  are  dissected 
up,  and  the  shaft  of  the  Y  is  completed  by  dividing  the  web  in  the  mid- 
line. The  arm  is  then  loosened  from  the  trunk  and  raised.  The  flaps 
are  then  turned  in  to  the  axillarv  defect  and  sutured,  the  anterior  being 


632 


PLASTIC    SURGERY 


Fig.  737. — Operation  for  the  restoration  of  the  axilla  by  the  use  of  an  anterior  and  pos- 
terior flap  (Defontaine) . — The  dark  lines  indicate  the  incisions  made  for  outlining  the  flaps 
A  and  B  dividing  the  web.  After  the  arm  is  raised  the  flaps  A  and  B  when  drawn  together 
overlap,  A  being  placed  inside,  and  B  outside. 


Fig.  738. — Operation  for  the  restoration  of  the  axilla  (Piechaud). — i  and  2.  The  dark 
lines  indicate  the  incisions  outlining  the  flaps  A  and  B,  and  dividing  the  web.  3.  Shows 
the  flaps  shifted  in  to  form  the  axilla,  the  flap  A  being  placed  above  the  flap  B. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


633 


inside,  and  the  posterior  outside.  All  other  defects  are  then  closed  by 
undercutting.  In  this  operation,  however,  the  central  portion  and 
tip  of  each  triangular  flap  is  composed  of  scar  tissue,  and  slough  will 
usually  follow.  Moreover,  the  closure  of  the  defects  on  the  chest  and 
arm  are  seldom  possible,  because  of  the  lack  of  a  normal  skin  (Fig.  737). 
Piechaud's  operation  is  based  on  the  same  principle  as  that  of 
Defontaine.  He  raises  much  wider  triangular  flaps  from  the  chest 
wall  in  front  and  back,  the  bases  of  the  triangles  being  inward.     After 


Fig.  739. — Operation  for  the  restoration  of  the  axilla  (Berger). — i.  The  dark  lines 
indicate  the  incisions  made  to  form  the  flaps  A  and  B.  The  anterior  incision  being  at  the 
junction  of  the  skin  of  the  chest  with  the  web,  and  the  posterior  at  the  junction  of  the  skin 
of  the  arm  with  the  web.  These  incisions  are  joined  by  a  transverse  cut  across  the  bottom 
of  the  web.  2.  Shows  the  scar  tissue  flaps  in  position.  The  flap  A  filling  the  arm  defect, 
and  B  filling  the  chest  defect. 

dividing  the  contracture  and  dissecting  up  the  flaps,  he  turns  them  in 
to  form  the  axilla,  the  anterior  flap  lying  in  front  of  the  posterior  flap. 
All  other  wounds  are  also  sutured  so  that  the  gaps  are  entirely  closed. 
This  procedure  is  much  better  than  that  of  Defontaine,  inasmuch  as 
the  flaps  are  larger,  the  blood  supply  is  better,  and  there  is  little  scar 
tissue  included.  This  operation  depends  for  its  success  on  the  presence 
of  adjacent  normal  skin  (Fig.  738). 

Berger's  operation  for  extensive  contracture,  although  in  my 
experience  without  merit,  will  be  described  for  the  sake  of  completeness. 
He  makes  an  incision  in  front  along  the  full  length  of  the  thoracic 
margin  of  the  contracture,   and  a  similar  incision  behind  along  the 


634 


PLASTIC    SURGERY 


Fig.  740. — The  use  of  a  sliding  flap  from  the  chest  to  reUeve  dense  adhesions  between  the 
arm  and  chest  wall. — When  the  adjacent  skin  of  the  chest  is  not  involved,  with  scar  tissue  for 
any  considerable  distance  from  the  web  binding  the  arm  to  the  thorax,  a  large  lateral  flap 
may  be  raised  and  shifted  into  a  raw  surface  prepared  for  it  on  the  arm.  After  healing 
has  taken  place  the  pedicle  is  divided,  preferably  a  little  at  a  time.  When  the  division  is 
complete  the  web  is  divided  and  the  free  end  of  the  flap  is  turned  around  the  arm  and 
sutured.     The  chest  defect  is  grafted. 


Fig.  741. — Obliteration  of  the  axilla  by  a  partial  thick  web  of  scar  tissue,  following  a 
burn. — I.  Note  the  limit  of  abduction.  The  axilla  was  formed  by  shifting  flaps  from  the 
chest  and  back.  2.  Photograph  taken  three  weeks  after  operation.  During  the  last  three 
years  the  function  of  the  arm  has  become  practically  normal. 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES 


635 


arm  margin  of  the  contracture.  A  transverse  cut  along  the  k)wer 
border  of  the  web  unites  the  lower  extemities  of  these  incisions  In 
front  a  flap  is  dissected  up  with  its  base  on  the  arm.     Behind,  a  flap 


Fig.  742. — Obliteration  of  the  axilla  and  contracture  of  the  cubital  space  following  a 
burn.  Duration  three  years. — i,  2  and  3.  The  wide  extent  of  the  scar  which  can  be  seen 
eliminates  the  use  of  the  greater  portion  of  the  adjacent  tissue  in  forming  the  new  axilla. 

is  dissected  up  with  its  base  on  the  chest.  The  arm  is  then  separated 
from  the  body  and  raised.  The  posterior  flap  is  sutured  to  the  skin  of 
the  chest,  and  the  anterior  flap  is  sutured  to  fill  the  arm  defect.     Both 


Fig.  743. — Obliteration  of  the  axilla  and  contracture  of  the  cubital  space,  continued. — 
I  and  2.  A  sharply  curved  flap  with  its  pedicle  above  was  raised  and  straightened  and  after 
division  of  the  web  was  turned  in  to  form  the  apex  of  the  axilla.  Its  free  end  reached  to 
the  posterior  axillary  line  where  it  was  sutured.  The  defect  from  which  it  was  raised  was 
grafted,  as  were  the  other  uncovered  areas.  The  photographs  were  taken  one  year  after 
the  operation  and  show  considerable  improvement  in  the  condition.  3.  Taken  two  years 
later.      Note  the  ability  to  raise  the  arm.      Function  is  now  quite  perfect. 

of  these  flaps  are  composed  almost  entirely  of  scar  tissue  and  their  use- 
fulness is  problematical  (Fig.  739). 

In  my  own  experience  I  have  found  in  the  large  majority  of  cases 
that  the  skin  of  the  arm  and  chest,  and  adjacent  portion  of  the  abdo- 


636 


PLASTIC    SURGERY 


men,  is  often  entirely  infiltrated  or  replaced  by  scar,  and  few  if  any  of 
the  operations  described  can  be  carried  out  as  desired.  I  have  been 
forced  on  several  occasions  to  form  the  axilla  by  means  of  a  long  curved 
flap  taken  from  the  top  of  the  shoulder  and  clavicular  region,  or  from 
the  scapular  region,  and  to  cover  the  rest  of  the  defect  with  skin  grafts. 
Preservation  of  the  Contour  of  the  Breast.— In  those  cases  of  chronic 
fibro-cystic-mastitis  which  require  only  removal  of  breast  tissue,  Willard 
Bartlett  has  devised  an  ingenious  operation  in  which  the  contour  of 
the  breast  is  preserved,  and  he  reports  good  results.  He  makes  a 
crescentic  skin  incision  in  the  fold  under  the  breast,  lifts  the  breast  off 
the  chest  wall,  dividing  all  attachments  with  the  cautery,  and  packs 
this  cavity  with  gauze.  He  then  strips  back  the  skin  over  the  gland 
with  the  cautery,  being  very  careful  to  avoid  injury  to  the  skin,  and 


Pig.  744. — Obliteration  of  the  axilla  with  contracture  of  the  cubital  space,  continued. — 
I  and  2.  Note  the  height  of  the  axilla  in  front  and  behind.  3.  Shows  the  arm  and  forearm 
extended  following  a  plastic  operation  with  grafting.  The  use  of  a  pedunculated  flap  from 
the  chest  or  abdomen  was  not  possible  for  the  cubital  space,  on  account  of  such  extensive 
scar  involvement.  The  lesson  taught  in  this  case  is  the  importance  of  allowing  sufficient 
time  to  elapse  between  operations,  for  shrinkage,  stretching  and  natural  adjustment  to 
take  place.      If  this  is  done  we  will  find  many  difficult  problems  partially  solved  for  us. 

removes  the  breast  tissue.  Absolute  hemostasis  is  essential,  and 
after  this  has  been  secured,  a  firm  pack  is  inserted  into  the  cavity.  He 
then  removes  from  the  abdominal  wall,  the  buttock  or  the  thigh,  a 
mass  of  fat  one-half  larger  than  the  breast  tissue  which  has  been 
extirpated  (to  allow  for  subsequent  shrinkage)  and  fills  the  breast 
cavity  with  it.     He  closes  the  wound  without  drainage. 

Hernia  of  the  Lung.— The  plastic  surgeon  is  occasionally  called 
upon  to  close  a  defect  in  the  bony  framework  of  the  thoracic  wall 
through  which  there  is  a  hernia  of  the  lung.  This  may  follow  injury 
or  operation.  I  have  found  that  when  a  hernia  protrudes  through  an 
opening  involving  only  a  comparatively  small  portion  of  one  or  two 
ribs,  after  freeing  the  overlying  soft  parts  from  the  pleura,  a  graft  of 


SURGERY  OF  THE  NECK,  TRUNK,  AND  EXTREMITIES      637 

fascia  lata  sutured  snugly  over  the  defect  will  ordinarily  close  it  and 
prevent  recurrence.  When  the  lung  protrudes  through  a  larger  open- 
ing (usually  following  wounds),  the  transplantation  of  cartilaginous 
ribs  after  separation  of  the  overlying  soft  parts  from  the  pleura,  is 
usually  the  operation  of  choice.  Chutro,  Okinczyc,  and  others,  have 
had  good  results  with  this  method. 

BIBLIOGRAPHY 
Neck  and  Trachea 

Abbe,  R.     "Anns.  Surg.,"  v,  1887,  318. 

AL.A.GN.A,  G.     "Deutsche  Zeit.  f.  Chir.,"  Nov.,  1913,  c.x.xv,  613. 

Berger,  p.     "Bull,  et  mem.  de  Soc.  de  Chir."     Paris,  1889,  n.  s.,  xv,  684 
BuRKET,  W.  C.     "Johns  Hopkins  Hospitall  Bull.,"  Feb.,  1918,,  35. 

Chiari,  O.     "Monatschr.  f.  Ohrenk.,"  1915,  xlix,  337. 

Dui'UVTREN.     "Lecons  Orales,"  1S32,  ii,  66. 

E ARLE,  H.     "'Medico-Chir.  Trans.,"  v,  May  10,  1814,  96. 

"Medico-Chir.  Trans.,"  vii,  June  25,  1816,  411. 
EsSER,  J.  F.  S.     "Arch.  f.  klin.  Chir.,"  Nov.,  191 7,  385. 

Franxk,  O.     "Munchen  med.  Wchnschr.,"  Feb.  8,  1910,  285. 

Grosse.     "Centralbl  f.  chir.,"'  1901.  mo. 

Hartmaxx.     Duplay  &  Reclus:  "Traite  de  Chirurgie,"  v,  436. 
HoFMANX,  M.     "Archiv  f.  klin.  Chir.,"  xcii,  1910,  32. 

Jacobsox,  a.     "Archiv  f.  klin.  Chir.,"  1886,  Bd.  33,  758. 
James,  J.  H.     "Medico-Chir.  Trans.,"  iii,  Jan.  11,  1825,  152. 

KoxiG,  F.     "Berliner  klin.  Wchnschr.,"  1896,  No.  51,  1129. 
KusTER.     "Verh.  d.  Deutsch.  Gesellsch.  f.  Chir.,"  1893,  80. 

L.\xderer.     Grosse:  "Centralbl.  f.  Chir.,"  1901,  mo. 
Le  Fort.     "Bull,  de  la  Soc.  de  Chir."     Paris,  1864,  489. 
Levit,  H.     "Archiv  f.  klin.  Chir.,"  xcvii,  Nr.  3,  686. 

v.Maxgoldt,  F.     "Archiv  f.  klin.  Chir.,"  Bd.  59,  1899,  926. 
MoRESTix,  H.     "Bull,  et  mem.  soc.  de  Chir.  de  Par.,"  1915,  1381. 

"Bull,  et  mem.  soc.  de.  Chir.  de  Par.,"  1918,  776. 
MouRE,  E.  J.  &  Caxuyi,  G.     "Rev.  de  Chir."     Paris,  1916,  x.xxv,  Xo.  7-8,  i. 
Mutter,  T.  D.     "Amer.  Jour.  ^led.  Science,"  1842,  iv,  n.  s.  66. 

NowAKOWSKi,  K.     "Archiv  f.  klin.  Chir.,"  Bd.  90,  1909,  847. 

Photi.vdes,  &  Lardy.     "Rev.  med.  de  la  Suisse  Rom."  1893. 

Reid.     Quoted  by^Hartmann,  "Duplay  &  Reclus:  "Traite  de  Chirurgie,"  v,  437. 


638  PLASTIC    SURGERY 

SCHEPELMANN,  E.     "Archiv  f.  klin.  Chir.,"  191 2,  xcviii,  243. 
ScHiMMELBUSCH.     "Verh.  d.  deutsch.  Gesellsch.  f.  Chir.,"  i8q3,  78 

Walther,  C.     Duplay  &  Reclus:  "Traite  de  Chirurgie,"  t.  v,    595. 

Trunk  and  Axilla 

Bartlett,  W.     "Anns.  Surg.,"  Sept.,  1917,  208. 

Beck,  C.     "Med.  Rec,  N.  Y.,"  July  14,  1906,  41- 

Berger  &  Banset.     "Chirurgie  orthopedique."     Paris,  1904,  180 

Bevan,  a.  D.     "Surg.  Clin."     Chicago,  1918,  ii,  717. 

Chaput.     "Bull,  de  la  Soc.  de  Chir."     Paris,  1904,  604. 

Chutro,  p.     "Bull.  mem.  soc.  de  chir.  de  Par.,"  1918,  pp.  349,  693 

Dejtontaine.     "Archives  prov.  de  chir.,"  1892,  i,  145. 

Elsberg,  C.  a.     "Anns.  Surg.,"  Dec.  1915,  678. 
d'Este,  S.     "Rev.  de  Chir.,"  Feb.,  191 2,  164. 

V.  Hacker.     "Archiv  f.  klin.  Chir.,"  Bd.  37,  1888,  91. 
Halsted,  W.  S.     "Jour.  Amer.  Med.  Assn.,"  Feb.  8,  1913,  416. 

JOBERT  (de  Lamballe).     "Traite  de  chirurgie  plastique,"  ii,  40. 

Legtjeu,  F.     In  Cornilus:  "These  de  Paris,"  1899,  18. 

McCxjRDY,  S.  L.     "Surg.,  Gyne.  &  Obst.,"  Feb.,  1913,  209. 
Morestin,  H.     "Bull,  de  la  Soc.  anatomique,"  May,  1903,  459. 

"Jour,  de  Chir."     Paris,  Nov.,  1911,  509. 

"Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1918,  776. 

Okinczyc.     "Bull,  et  mem.  Soc.  de  Chir.  de  Par.,"  1918,  350. 

Parker,  C.  A.     "Jour.  Amer.  Med.  Assn.,"  Aug.  19,  1916,  565. 
Pi^CHAUD.     "Rev.  d'orthop.,"  1896,  82. 

Qu£nu  and  Robineau.     "Rev.  internat.  de  Therap.  et  de  pharmacologie,"  1896,  304. 

Roux.,  E.     "Gaz.  des  hopitaux,"  June,  1901,  630. 

Shrady,  G.  F.     "Med.  Rec."     New  York,  Dec.  2,  1893,  717. 

Tansini.     "La  Clinica  Chirurgica,"  1901,  241. 
"Riforma  med.,"  1896,  70. 

Weichert,  M.     "Berliner  klin.  Wchnschr.,"  Jan.  20,  1913,  103. 


CHAPTER  XXIV 
SURGERY  OF  THE  EXTREMITIES 

General  Considerations.- — The  majority  of  plastic  operations  on 
the  extremities  are  made  necessary  by  extensive  losses  of  substance, 
due  to  burns,  operations,  injuries  or  ulceration,  or  to  the  vicious  cica- 
trices following  these  lesions.  The  destruction  of  tissue  may  occur 
anywhere  on  the  extremities,  but  in  certain  situations  it  is  of  more 
importance  than  others,  especially  at  the  junction  of  the  limbs  with  the 
body,  in  the  neighborhood  of  the  joints,  on  the  sole  of  the  foot,  and  the 
palm  of  the  hand. 

Vicious  cicatrices  are  due  for  the  most  part  to  slow  unassisted 
healing  and  the  formation  of  an  extensive  amount  of  scar  tissue,  the 
part  having  assumed  the  most  comfortable  natural  position.  In  due 
time  the  scar  contracts,  h^perfiexion  or  extension  occurs,  and  the  parts 
may  be  bound  so  closely  together  that  for  all  practical  purposes  they 
are  fused  into  one  mass.  The  motion  of  involved  joints  may  be  par- 
tially or  completely  limited,  and  the  part  become  useless.  The  under- 
lying soft  parts  may  be  atrophied  by  long  continued  pressure,  and  often 
the  bone  is  shortened  and  distorted.  These  contractures  require 
radical  treatment. 

In  the  neighborhood  of  joints  such  as  the  knee,  elbow,  ankle,  the 
palm  of  the  hand,  and  sole  of  the  foot,  a  thick  soft  resistant  skin  is 
necessary.  As  a  general  rule  after  the  relief  of  flexor  contractures, 
the  part  should  be  kept  in  extension  until  the  grafts  or  flaps  have 
healed,  and  in  flexion  after  extensor  contractures. 

TREATMENT  OF  LOSS  OF  SUBSTANCE 

The  Use  of  Abduction. — Parker  and  others  treat  extensive  burns 
of  the  axilla,  arm,  and  adjacent  portion  of  the  chest  wall,  by  abducting 
the  arm  and  maintaining  this  position  with  a  plaster  cast  which  is 
removed  for  purposes  of  cleanliness  each  day.  After  the  sloughs  have 
come  away,  the  wound  is  covered  completely  with  overlapping  strips 
of  adhesive  plaster  which  are  changed  every  two  or  three  days,  this 
t\pe  of  dressing  being  continued  until  healing  is  complete.     By  the 

639 


640 


PLASTIC    SURGERY 


use  of  this  method  it  is  said  that  no  contracture  occurs,  and  that  the 
necessity  for  skin  grafting  is  eliminated.  It  can  also  be  used  on  the 
neck  and  thigh  where  they  join  the  body.  My  experience  has  been 
that  the  results  with  this  method  are  much  accelerated  by  the  use  of 
skin  grafts. 

The  Use  of  Skin  Grafts.^Skin  grafts  may  be  placed  on  a  fresh 
wound  or  on  a  clean  ^sterile)  granulating  surface,  with  equal  success, 


Fig.  745. — Congenital  cavernous  hemangioma  involving  the  upper  extremity  and  chest 
(Surg.  Xo.  29316). — Anterior  view.  There  was  pain  and  loss  of  function.  X-ray  showed 
atrophy  of  the  bones  and  calcified  areas  scattered  through  the  soft  parts.  The  pectoral 
muscles  were  Involved  and  huge  blood  channels  penetrated  the  chest  wall.  The  case  was 
found  to  be  inoperable. 


and  are  very  useful  in  hastening  the  healing  of  extensive  wounds.  By 
their  aid  contractures  may  in  many  instances  be  prevented;  in  others, 
even  if  a  certain  amount  of  contracture  follows,  it  is  much  less  difficult 
to  correct  than  if  healing  has  taken  place  unassisted. 

On  wounds  away  from  joints  any  of  the  types  of  skin  grafts  may  be 
used  with  satisfactory  results.  If  the  loss  of  substance  is  over  a  joint, 
for  instance  in  the  cubital  or  popliteal  spaces,  we  must  select  the  type 


SURGERY  OF  THE  EXTREMITIES 


641 


of  graft  under  which  contracture  is  least  likely  to  occur.  Ollier-Thiersch 
grafts  are  often  used,  but  as  contracture  frequently  takes  place  beneath 
a  graft  of  this  type,  it  is  more  satisfactory  to  use  whole-thickness  skin 
in  these  situations.  I  have  seen  some  good  results  with  small  deep 
grafts  around  the  elbow;,  wrist  and  knee,  but  this  type  is  not  to  be 
recommended  in  these  situations,  as  contracture  often  takes  place 
after  healing. 


Fig. 


;46. — vSurg.    Xo.   29316),  continued. — Posterior  view  of  hemangioma  involving  the 

upper  extremity. 


Other  Methods. — Occasionally  gliding  flaps  may  be  used  (French 
method).  The  Indian  method  is  suitable  in  certain  situations,  but 
frequently  the  condition  of  the  surrounding  tissue  and  the  situation 
of  the  wound  contraindicates  the  use  of  a  flap  from  neighboring 
tissue. 

The  procedure  of  choice,  when  a  thick  pad  of  fat  and  skin  is  re- 
quired under  which  no  contracture  will  occur,  is  the  flap  from  a  distant 
part  (Italian  method). 


642  PLASTIC    SURGERY 

TREATMENT  OF  VICIOUS  CICATRICES 

Excision,  or  Division,  with  Skin  Grafting.- — After  cicatrices  have 
formed  the  best  method  of  treatment  is  to  excise,  if  possible,  all  of  the 
contracting  scar.  If  the  defect  left  by  this  excision  is  not  in  the 
neighborhood  of  a  joint,  it  may  be  successfully  treated  with  any  of  the 
types  of  skin  grafts.  On  the  other  hand,  if  the  defect  is  close  to  a 
joint,  my  experience  has  been  that  grafts  of  whole-thickness  are  to  be 
preferred.  If  the  scar  involves  too  large  an  area  for  complete  excision 
wherever  it  is  situated,  it  should  be  divided,  the  contracture  relieved, 
and  the  defect  filled  with  a  graft  of  whole-thickness.  In  this  way  the 
continuity  of  the  scar  is  broken  with  a  mass  of  tissue  which  will  stretch 
in  due  time;  the  relaxation  will  change  the  character  of  the  remaining 
scar  so  that  it  will  become  more  stable,  and  if  properly  massaged 
and  manipulated  wiU  answer  very  well,  without  further  operative 
interference. 

The  Use  of  Pedunculated  Flaps.— In  the  neighborhood  of  joints, 
or  in  exposed  portions,  either  after  complete  excision  of  the  cicatrix 
or  after  a  simple  division,  the  most  dependable  results  are  secured  by 
the  use  of  pedunculated  flaps  of  skin  and  subcutaneous  fat  from  a  dis- 
tant part.  In  using  a  flap  from  a  distant  part  every  effort  shoiild  be 
made  to  place  the  patient  in  a  comfortable  position.  This  is  a  com- 
paratively simple  matter  when  a  flap  from  the  abdomen  is  sutured  to 
the  arm.  but  when  the  flap  is  from  one  lower  extremity  to  the  other, 
the  problem  becomes  difficult.  In  all  cases  in  which  the  limbs  have  to 
be  fastened  together,  it  has  been  found  by  experience  that  it  is  ordi- 
narily more  comfortable  for  the  patient  if  the  shoulders  and  buttocks 
rest  on  the  bed.  A  position  must  be  determined  with  the  cooperation 
of  the  patient  which  is  comfortable,  and  if  possible  exactly  this  same 
attitude  assumed  and  maintained  after  the  flap  is  in  place,  and  the 
immobilizing  plaster  cast  has  been  applied.  A  slightly  greater  degree 
of  rotation  may  make  intolerable  a  position  which  otherwise  would  be 
fairly  comfortable.  It  is  a  difficult  matter  to  apply  an  immobilizing 
dressing  to  a  patient  relaxed  by  a  general  anesthetic,  which  will  be  com- 
fortable after  consciousness  returns.  To  provide  for  this  a  cast  may  be 
fitted  on  a  day  or  two  before  operation  with  the  parts  in  the  desired 
position,  and  it  may  subsequently  be  cut  and  removed.  Then  at  the 
time  of  operation  after  the  flap  has  been  sutured  into  position,  the 
cast  may  be  replaced.  The  successful  use  of  such  a  cast,  however,  is 
a  questionable  matter,  as  the  necessities  of  the  operation  often  require 


SURGERY  OF  THE  EXTREMITIES 


643 


changes  in  the  previously  calculated  length  of  the  pedicle  or  in  the 
angle  in  which  the  part  is  placed. 

Nelaton  and  Ombredanne  have  suggested  that  the  sound  leg  be 
placed  in  the  desired  position  in  a  removable  plaster  cast  which  is  so 
cut  that  the  proposed  flap  will  not  be  interfered  with.  Then,  when  the 
flap  is  subsequently  raised,  the  cast  is  reapplied  and  used  as  a  fixed 
point,  so  that  the  cast  to  hold  the  limbs  together  can  be  more  easily  and 
comfortably  applied.     This  is  a  very  useful  procedure.  i 

Great  care  must  be  taken  that  skin  should  not  be  in  contact  with 
skin.     The  use  of  powder  and  properly  placed  gauze  pads  will  prevent 


I  234 

Fig.  747. — Method  of  closing  bone  defects  with  sliding  skin  flaps  (Thevenard). — I. 
The  dark  lines  AA'  and  BB'  indicate  the  upper  and  lower  incisions  marking  out  the  flaps 
of  skin  and  subcutaneous  tissue.  DD'  and  CC  indicate  the  incisions  by  which  the  skin 
and  periosteal  margins  of  the  bone  defect  are  removed.  2.  Cross  section  showing  the 
healthy  bone  after  operation.  The  drill  passed  through  the  muscle  has  perforated  the 
bone,  and  has  been  threaded  with  silver  or  bronze  wire.  3.  The  skin  flaps  have  been  shifted 
inward  and  fixed  in  the  bottom  of  the  groove  in  the  bone.  Xote  that  the  wires  are  tied 
over  gauze  rolls.  4.  Appearance  of  the  leg  after  suturing  is  completed.  Xote  the  alter- 
nating position  of  the  sutures. 

this.  All  bony  prominences  must  be  carefully  padded  and  thick 
pads  should  be  placed  between  the  limbs  when  they  cross,  or  when  one 
rests  on  the  other.  It  is  better  to  over-pad  than  to  under-pad,  as  a 
pressure  slough  is  a  disgraceful  and  unnecessary  complication.  The 
ankle,  knee,  or  heel,  where  they  rest  on  the  bed  must  also  be  thoroughly 
padded.     The  flap  should  be  inspected  from  time  to  time. 


\ 


:methods  of  obliterating  bone  defects 

The  defects  left  by  the  removal  of  portions  of  the  long  bones  for 
steomyelitis  are  often  dilhcult  to  heal.     Grafts  may  be  placed  on  the 


644  PLASTIC    SURGERY 

bone  itself  or,  if  granulation  tissue  forms  on  the  surface  of  the   bone, 
this  area  may  be  grafted,  after  the  proper  preparation. 

If  the  surrounding  skin  is  normal  to  the  margin  of  the  bone  defect, 
then  after  the  bone  has  been  thoroughly  cleaned  out,  lateral  flaps  may 
be  shifted  in  by  the  French  method,  and  their  edges  secured  to  the 
bottom  of  the  gutter  by  tacks  with  lead  plates,  wire  staples,  or  sutures. 
The  operation  of  Trevenard  is  a  very  good  one  and,  with  modifications 
in  the  method  of  securing  the  flaps  to  bone,  may  be  used  on  upper  or 
lower  extremity.  The  diagrams  of  this  procedure  are  self-explanatory 
(Fig.  747). 

Pedunculated  flaps  from  the  adjacent  skin,  or  from  distant  parts 
may  also  be  used  to  fill  the  defect,  and  may  be  held  in  position  by 
sutures,  tacks,  or  by  the  dressings  alone. 

It  may  be  necessary  to  relieve  the  tension  or  to  excise  the  scar, 
if  the  wound  is  also  surrounded  by  scar  tissue,  before  satisfactory  heal- 
ing can  be  obtained  by  any  method.  A  tight,  thin  scar  immediately 
surrounding  a  bone  defect  (as  in  any  other  situation)  is  always  a  source 
of  trouble. 

UPPER  EXTREMITY 

ARM  AND  ELBOW 

Loss  of  Substance.^ — In  treating  wounds  around  the  elbow  healing 
must  be  accelerated  by  the  use  of  grafts  or  flaps,  as  seems  best  for  the 
special  case.  It  is  often  advisable  to  excise  an  ulcer  in  this  region  and 
to  treat  the  gap  as  a  fresh  wound.  Ordinarily  in  treating  an  extensive 
loss  of  substance — let  us  say  of  the  cubital  space — we  should  place  the 
arm  in  extension  and  keep  it  in  that  position  until  healing  is  complete. 

Contractures.— In  cases  in  which  the  destruction  of  skin  has  in- 
volved the  entire  arm,  with  or  without  adherence  to  the  chest  wall, 
we  often  find  in  addition  to  the  ordinary  tight  scar,  at  one  point — 
usually  at  the  middle  or  at  the  junction  of  the  middle  and  upper  thirds 
— a  definite  constriction  from  2.5  to  5.  cm.  (i  to  2  inches)  wide.  Often 
this  rigid  band  compresses  the  soft  parts  beneath,  so  that  the  size  and 
outline  of  the  bone  can  be  seen.  Relief  of  the  constriction  may  be 
brought  about  by  dividing  the  scar  parallel  to  the  length  of  the  arm 
down  to  normal  tissue  in  one  or  more  places,  and  when  this  has  been 
accomplished  the  gap  is  filled  with  skin  grafts,  or  better  still  with  a 
flap  from  the  shoulder.  This  may  be  done  before  or  after  the  separa- 
tion of  the  arm  from  the  trunk. 

Contracture  of  the  elbow  is  usually  on  the  flexor  side,  although 


SURGERY  OF  THE  EXTREMITIES 


645 


occasionally  a  dense  scar  over  the  extensor  surface  will  prevent  flexion. 
In    this    situation    as    in    all    others    around    joints,    the  problem  is 


Fig.  748.  Fig.  749. 

Pig.  748. — Arteries  of  the  skin  of  the  posterior  surface  of  the  arm  (Manchot). — i. 
Posterior  circumfle.x  artery.  2.  Radial  recurrent  artery  with  its  cutaneous  branches. 
3  and  4.    Cutaneous  branches  from  the  brachial  artery. 

Fig.  749. — Arteries  of  the  skin  of  the  anterior  surface  of  the  arm  (Manchot). — i. 
Anterior  circumflex  artery.  2.  Brachial  artery.  3.  Inferior  profunda  artery  with  its 
cutaneous  branches.  4-15.  Cutaneous  branches  of  the  brachial  artery.  16.  Cutaneous 
branches  of  the  superior  profunda  artery. 


usually  complicated  by  the  presence  of  dense  scar  involving  the  arm 
and  the  forearm. 


646 


PLASTIC    SURGERY 


Fig.  750.  Fig.  751. 

Fig.  750. — -Arteries  of  the  skin  of  the  anterior  surface  of  the  forearm  (Manchot). — 
I.  Brachial  artery,  a^yd.  Cutaneous  branches  from  the  brachial  artery.  2,  3  and  4.  Cuta- 
neous branches  from  the  median  artery.  5.  Superficial  cubital  branch  of  the  brachial 
artery.  6.  Radial  artery.  7.  Cutaneous  branches  of  the  radial  recurrent  artery.  8.  Cu- 
taneous branches  of  the  radial  artery.     9.    Cutaneous  branches  of  the  ulnar  artery. 

Fig.  751. — The  arteries  of  the  skin  of  the  posterior  surface  of  the  forearm  (Manchot.). — 
I.  Recurrent  interosseous  artery.  2-12.  Cutaneous  branches  of  the  posterior  interosseous 
artery.  13  and  14.  Cutaneous  branches  of  the  ulnar  artery.  15-17.  Cutaneous  branches 
of  the  anterior  interosseous  artery.      18.   Radial  recurrent  artery. 


SURGERY    OF    THE    ?:XTREMrriES 


647 


I  23 

Fig.  752. — Web  binding  the  arm  and  chest  wall  together,  following  a  burn. — i  and  2. 
Anterior  and  posterior  views.  Note  the  limit  of  abduction.  The  deformity  was  corrected 
by  removal  of  the  scar  tissue  and  shifting  in  a  flap  from  the  anterior  wall,  and  one  from  the 
posterior  wall,  and  suturing  them  in  the  midline.  All  areas  not  covered  by  the  flaps  were 
grafted.  3.  Result  of  the  operation.  Note  the  level  of  the  axilla  in  front.  The  dark 
area  on  the  chest  is  the  area  which  was  grafted. 


Fig.  753. — Web  binding  the  arm,  continued. —  i.  The  level  of  the  axilla  posteriorly. 
The  dark  area  is  grafted.  2.  The  new  axilla  covered  with  normal  movable  skin.  Note 
the  width  of  the  flaps  forming  the  axilla,  and  the  amount  of  abduction.  The  functional 
result  is  perfect. 


1  23 

Pig.  754. — Bilateral  web  formation  following  an  extensive  burn. — i  and  2.  Front  and 
back  views,  showing  the  limit  of  abduction.  Note  the  scar  involvement  of  the  surrounding 
skin.  3.  The  webs  were  fairly  thin  and  were  utilized  in  making  flaps  to  form  the  new 
axillae.  Denuded  areas  were  grafted.  Photograph  taken  five  years  after  operation. 
Note  the  normal  appearance  of  the  axillae  and  the  abduction.  The  functional  result  is 
also  perfect. 


648 


PLASTIC    SURGERY 


Fig.  755. — Method  of  using  long  double-pedicled  flaps  (Croft). — i.  Shows  the  con- 
tracture. The  dotted  lines  indicate  the  flaps  A  and  B  which  are  separated  from  the  under- 
lying tissues  without  cutting  the  pedicles.  Later  the  lower  pedicle  of  each  flap  is  severed 
and  the  flaps  are  shifted  to  fill  defects  left  by  relieving  the  contracture.  2.  Indicates  the 
position  subsequently  occupied  by  the  flaps. 


Fig.  756. — Obliteration  of  the  cubital  space  with  scar,  following  an  old  burn. — i. 
Note  the  limitation  of  extension  caused  by  the  web,  which  extends  from  the  shoulder  to 
the  wrist.     2.   The  result  six  months  after  operative  interference. 


SURGERY  OF  THE  EXTREMITIES 


649 


Limitation  of  motion  may  be  slight  when  caused  by  a  narrow- 
band of  scar,  or  it  may  be  complete,  the  cubital  space  being  obliterated 
and  the  forearm  and  arm  in  this  region  fused  together  bv  a  dense 


scar. 


Fig.   757.  Fig.   758. 

Methods  of  reconstructing  the  cubital  space. 
Fig.   757. — Poncet's  operation. — A  single-pedicled    flap  with  pedicle  above  from  the 
thoracic  wall  is  used. 

Fig.   758. — Berger's  operation. — A  single-pedicled  flap  from  the  thigh  is  used. 

When  the  constricting  bands  are  thin,  and  the  surrounding  skin 
is  normal,  much  can  be  accompHshed  by  a  V-shaped  incision  which 
relieves  the  contracture,   or  bv  the  excision  of  the  band  through  a 


>. 


Fig.   759. — Method  of  restoring  the  cubital  space  by  means  of  a  pedunculated  flap  from 
the  abdominal  wall.      Note  the  position  of  the  pedicle. 

Z  or  S-shaped  incision,  and  then  suturing  the  edges.  When  the  scar 
is  more  extensive,  it  must  be  removed  and  the  gap  filled  with  a  graft 
of  whole-thickness  skin,  or  a  pedunculated  flap.     If  the  scar  is  dense  and 


6so 


PLASTIC    SURGERY 


involves  the  surrounding  skin  it  should  be  divided  over  the  joint,  and 
the  contracture  relieved,  then  as  much  as  may  be  desired  should  be 
removed  from  the  margins,  and  the  defect  filled  with  a  graft,  or  with  a 
pedunculated  flap. 

A  flap  may  be  obtained  from  the  skin  of  the  thorax  (Poncet  and 
others),  or  from  the  abdominal  wall  on  the  same  side  (Berger  and 
others).     When  the  skin  of  the  thorax  and  abdomen  is  infiltrated 


Pig.  760. — Gradual  stretching  of  the  tissues  (Moresiin) . — i.  The  ulcer  or  scar  has  been 
excised  and  normal  tissue  is  everywhere  exposed.  The  sutures  may  be  seen.  2.  Position 
of  flexion  after  suturing  normal  tissue  to  normal  tissue.  3.  Stretching  the  skin  after  heal- 
ing is  complete. 


with  scar,  Berger  utilizes  the  skin  of  the  thigh,  but  the  position  must  be 
extremely  uncomfortable,  and  in  these  cases  a  graft  of  whole-thickness 
should  be  tried  first. 

Flaps  from  the  same  situation  may  also  be  used  to  cover  the  elbow  |' 
after  relief  of  extensor  contractures. 

Excision  and   Suturing    of  Normal  Tissues  With  the  Part  in! 
Hyperflexion. — Morestin  has  devised  another  method  and  has  reported  I 


SURGERY    OF    THE    EXTREMITIES 


good  results.  He  excises  the  ulcer  or  contracture  completely  until 
normal  tissues  are  exposed  everywhere,  and  then  hyperflexes  the  part 
and  coapts  the  skin  with  sutures.     After  primary  healing  has  taken 


Fig.  761. — Unstable  scar  involving  the  tendons,  following  the  explosion  of  aluminium 
bronze  powder.  Duration  two  and  a  half  years. — i.  The  tightly  adherent  unstable  scar 
of  the  forearm  which  prevents  all  motion  of  the  fingers  and  wrist.  2.  The  area  was  excised 
and  a  broad  pedicled  flap  from  the  abdominal  wall  was  implanted.  The  \-iew  in  the  photo- 
graph is  from  above  downward,  the  chest  wall  being  below  and  the  forearm  across  the  body. 
3.  The  result  of  the  implantation.  4.  The  abdominal  flap  was  not  sufficiently  wide  to 
cover  the  tendons  so  the  normal  skin  on  the  other  side  of  the  forearm  was  shifted  over  in 
two  flaps  to  fill  the  defect,  and  the  raw  surface  was  covered  with  small  deep  grafts.  This  is 
an  unusual  case,  inasmuch  as  although  the  patient  was  apparently  well  nourished  there  was 
absolutely  no  subcutaneous  fat  on  the  abdominal  wall.  The  ultimate  result  has  been  sat- 
isfactory.    Function  is  much  improved,  and  there  is  no  further  tendency  to  ulceration. 

place  the  part  is  gradually  extended,  and  he  says  that  indue  time  nor- 
mal extension  can  be  secured  by  the  gradual  stretching  of  the  skin. 
He  has  utilized  this  method  at  the  junction  of  the  thigh  with  the  body, 


652 


PLASTIC    SURGERY 


and  in  the  popliteal  and  cubital  spaces.  In  my  experience  this  operation 
is  not  entirely  satisfactory,  unless  the  excised  area  is  comparatively 
small. 

FOREARM 

Loss  of  Substance. — Destruction  of  tissue  on  the  forearm  may 
follow  injury,  burns,  ulceration  or  operation.  The  treatment  depends 
to  a  large  extent  on  the  size,  situation  and  shape  of  the  defect,  and  the 


I  23 

Fig.  762. — Contracture  following  burn  of  the  forearm  and  wrist  of  a  child  aged  fourteen 
years.  Duration  twelve  years. — i.  There  is  shortening  of  the  forearm  and  bowing  of  both 
bones,  with  flexion  of  the  wrist  and  marked  outward  deflexion  due  to  dense  scar  tissue. 
2.  One  month  after  excision  of  the  scar  and  the  implantation  of  a  pedunculated  flap  of  skin 
and  fat  from  the  abdomen.  3.  One  year  later.  The  wrist  is  now  in  normal  position; 
the  radius  and  ulna  are  practically  straight,  and  function  is  much  iraproved.  Note  the 
size  and  splendid  condition  of  the  flap.  If  necessary  the  marginal  scar  can  be  made  less 
noticeable  later,  by  excision. 

condition  of  the  surrounding  skin.  For  instance,  if  the  defect  is  parallel 
to  the  length  of  the  forearm,  is  not  too  wide,  and  the  surrounding  skin 
is  normal,  it  may  be  closed  by  undercutting  and  sliding,  either  with 
or  without  relaxation  incisions.  Skin  grafts  or  pedunculated  flaps  may 
be  used  in  suitable  cases. 

Contractures. — Tightly  adherent  scars  of  the  forearm  may  be 
most  difficult  to  handle  on  account  of  the  frequent  involvement  of 
the  tendons  in  the  scar.  In  these  cases  the  scar  tissue  should  be 
carefully  dissected  out,  and  the  wound  covered  with  a  pedunculated 
flap  of  fat  and  skin  from  the  abdomen. 

If  the  defect  is  on  the  extensor  surface  the  forearm  may  be  passed  under 
a  double-pedicled  bridge  flap  from  the  abdominal  or  the  chest  wall.     A 


SURGERY  OF  THE  EXTREMITIES 


653 


similar  flap  from  the  back  may  be  used  if  the  flexor  surface  is  defective. 
I  prefer  a  broad  single-pediclcd  flap  from  the  abdominal  or  thoracic 


Fig.   763.  Fig.   764. 

Suggestions  for  the  use  of  bridge  flaps  from  the  thigh. 
Fig.    763. — For  the  back  of  the  forearm.  Fig.    764. — For  the  cubita'  space. 


Fig.   765. —  Method  of  using  a  bridge  flap  from  the  arm  for  covering  a  defect  on  the  back 

of  the  wrist  (v.  Hacker). 

wall,  for  the  relief  of  defects  whether  on  the  flexor  or  on  the  extensor 
surfaces,  and  have  had  good  success  with  them.     I  have  in  this  way 


654 


PLASTIC    SURGERY 


relieved  contractures  involving  the  entire  length  of  the  forearm  with 
single  flaps  from  the  abdominal  wall.  The  pedicle  may  be  above 
or  below,  according  to  the  requirements  of  the  case.  Skin  grafting  may 
also  be  used  with  success  in  selected  cases. 


Pig.  766.  Fig.  767. 

The  repair  of  defects  on  the  front  of  the  wrist. 
Fig.    766. — A  single  flap  with  pedicle  above.  FiG.    767. — A  double-pedicled  flap. 


Fig.  768.  Fig.  769. 

The  repair  of  defects  on  the  back  of  the  wrist  and  forearm. 
Fig.   768. — A  single  flap  from  the  thoracic  wall  with  pedicle  above. 
Fig.   769. — -A  double-pedicled  flap  from  the  abdominal  wall. 

Volkmaiui's  ischemic  contracture  will  not  be  considered  here 
as  it  is  essentially  an  orthopedic  problem. 

WRIST 

Loss  of  Substance. — In  the  early  treatment  of  wrist  defects 
contracture  must  be  avoided  by  over-correction,  and  healing  must 
be  hastened  by  skin  grafting. 


SURGERY  OF  THE  EXTREMITIES 


655 


Contractures.—  After    contracture    has    taken  place   I   have    had 
success  follow  thorough  division  of  the  scar,  especially  on  the  ulnar  side, 


Fig.  770. — Contracture  of  the  fingers  following  a  burn  due  to  electricity. — There  had 
been  an  extensive  burn  of  the  palm  and  wrist  with  tendon  destruction  and  complete  scar 
involvement.  Note  the  position  of  the  fingers  which  are  rigidly  flexed.  The  thick  pad 
of  skin  and  fat  implanted  on  the  wrist  is  for  the  purpose  of  forming  fat  channels  through 
which  the  newly  formed  or  lengthened  tendons  may  run. 


Fig.  771. — Tight  gauntlet  scars  of  the  hand  and  wrist  following  a  burn.  Duration 
six  months. — -The  tightness  of  the  scar  around  the  wrist  prevented  proper  function  of  the 
joint,  and  also  held  the  thumb  in  marked  abduction.  In  order  to  release  the  thumb  a 
transverse  Incision  down  to  normal  tissue  was  made  across  the  wrist  at  the  base  of  the 
thumb,  and  a  longitudinal  incision  was  made  along  the  ulna  side  of  the  wrist.  Both  of 
these  incisions  gaped  quite  widely  and  were  filled  with  whole-thickness  grafts.  The  photo- 
graphs taken  after  two  weeks  show  the  grafts  healed  and  the  amount  of  flexion  possible 
for  the  thumb.  The  function  of  the  wrist  and  thumb  have  steadily  improved  since  opera- 
tion.     The  grafted  areas  can  be  seen  in  2  and  3. 

until  all  contracture  was  relieved.     The  defect  was  then  tilled  with 
a  graft  of  whole-thickness  skin.     A  similar  result  may  be  obtained 


656 


PLASTIC    SURGERY 


with  a  pedunculated  flap,  but  the  simpler  procedure  should  be  tried 
first. 

The  wrist  may  be  passed  through  a  double-pedicled  bridge  flap 
on  the  abdominal,  chest  wall,  or  back,  according  to  the  situation 
of  the  lesion,  or  a  single-pedicled  flap  from  the  same  localities 
"(Tuffier,  Rochard  and  others)  with  pedicle  above  or  below,  may  be 
used  with  success. 

The  forearm  or  wrist  may  be  passed  through  a  bridge  flap  on 
the  thigh,  but  the  position  is  awkward  and  this  region  should  not  be  used 
unless  the  others  are  unavailable. 

Some  of  the  wrist  contractures  show  extensive  flexion  or  extension, 
and  in  old  cases  where  the  shape  of  the  articulating  surfaces  has  been 


Pig.  772. — Method  of  using  a  wire  cage  over  a  grafted  area  on  the  thumb. — Note  the 
distance  the  wire  mesh  is  held  away  from  the  wound  by  the  felt  pads,  and  its  use  as  a  splint. 
Also  the  rubber  impregnated  material  holding  the  graft  in  place. 

distorted  it  may  be  impossible  to  restore  function  completely,  even 
when  all  tension  has  been  relieved. 


HAND 

Loss  of  Substance. — On  the  back  of  the  hand  the  defect  may  be 
covered  with  skin  grafts  of  any  type,  but  preferably  with  large  grafts, 
as  the  scarring  is  less  noticeable.  On  the  palm  the  only  type  of  graft 
which  promises  permanent  results  is  of  whole-thickness.  When  the 
destruction  is  deep,  pedunculated  flaps  should  be  used  on  the  dorsum 
or  palm  of  the  hand.  A  reasonably  thick  flap  on  either  palm  or  dorsum 
in  due  time,  will  shrink  and  be  very  little  thicker  than  the  normal  sur- 
rounding skin. 

Contractures. — These  may  vary  in  extent  from  that  of  any  portion 
to  complete  involvement.     The  flexor  type  is  the  most  common. 

Horrible  deformities  due  to  cicatricial  contractures  are  found  on 


SURGERY  OF  THE  EXTREMITIES 


657 


the  hand,  and  the  effect  of  the  distortion  is  unbelievable  unless  seen. 
After  the  contracture  has  been  relieved,  if  skin  grafting  is  decided  on, 
only  the  whole-thickness  graft  should  be  considered,  as  recontraction 


Pig.  773. — Contracture  of  all  the  fingers  following  severe  infection  treated  by  multiple 
incisions. — In  this  case  the  only  method  of  treatment  promising  relief  would  be  the  implan- 
tation of  a  pedunculated  flap  into  the  palm  and  wrist.  Then  the  lengthening  or  reconstruc- 
tion of  the  tendons. 

will  often  occur  when  other  types  are  used.  I  have  had  good  success 
with  this  method  in  the  relief  of  contractures  on  the  dorsum  and  on  the 
palm  of  the  hand  and  fingers,  and  several  years  ago  reported  a  number 
of  cases  treated  bv  this  method.  ^ 


Fig.  774. — Contracture  of  the  hand  following  a  burn.  Duration  twenty  years. — i  and 
2.  Note  the  limit  of  extension.  The  flexion  of  the  little  and  ring  fingers  is  especially  marked 
and  atrophy  has  occurred.  3.  After  relief  of  the  contracture  a  pedunculated  flap  from  the 
abdominal  wall  with  pedicle  above,  was  implanted.  Photograph,  (from  above),  taken  two 
weeks  later  and  just  before  the  pedicle  was  cut. 

The  use  of  the  pedunculated  flap  from  the  thoracic  or  abdominal 
wall  (Berger,  Fontan,  ]SIurphy  and  others),  or  from  the  back,  buttock. 


'Davis.  J.  S.,  "  Surg.,  Gyne.  &.  Obst.,"  July,  1917,  i. 


» 


6^8 


PLASTIC    SURGERY 


or  thigh,  may  be  used  to  cover  a  defect  on  the  dorsum  or  palm  of  the 
hand  accordmg;  to  its  situation. 


I  234 

Pig.  775. — Contracture  of  the  hand,  continued. — i.  The  position  and  width  of  the 
pedicle  can  be  seen.  Photograph  taken  just  before  the  pedicle  was  cut.  2  and  3.  Taken 
two  weeks  after  cutting  the  pedicle.  Note  the  very  thick  pad  of  fat  and  the  excessive 
amount  of  skin.  4.  Taken  eight  months  later.  Note  the  shrinkage  in  the  flap  and  also 
the  amount  of  extension  possible.  This  flap  is  to  be  left  in  place  some  time  longer  and 
m.assage  and  passive  motion  continued  on  the  fingers,  in  order  that  the  joint  surfaces  may 
graduallj'  adjust  themselves,  as  there  has  been  considerable  distortion  during  the  long 
continued  flexion.  Later  a  portion  of  the  fat  will  be  removed  from  the  flap,  and  excess 
skin  will  be  utilized  on  the  flexor  surface  of  the  proximal  phalanges  of  the  middle,  ring 
and  little  fingers.  The  gradual  readjustment  of  joint  surfaces,  and  the  stretching  of  the 
ligaments  in  these  cases  is  most  important  if  normal  function  is  to  be  obtained. 


12  3 

Fig.  776. — Contracture  of  the  hand  following  a  phosphorus  burn.     Duration  three  | 
years. — i    and    2.   The   limit    of   extension.     This   completely   incapacitated   the   patient 
for  his  work.     An  unsuccessful  attempt  was  made  to  relieve  the  condition  with  a  whole- 
thickness  graft.     3.   Two   weeks   after  the   implantation   of   a   flap   from   the   abdominal 
wall.      Note  the  raw  surface  left  after  cutting  the  pedicle.     This  was  fitted  into  position. 

Morestin  used  the  lax  skin  of  the  opposite  breast  to  cover  defects 
on  the  dorsum  of  the  hand,  and  Ombredanne  obtained  a  flap  from  the 
opposite  forearm  near  the  elbow  for  covering  a  defect  in  the  palm. 


SURGERY  OF  THE  EXTREMITIES 


659 


The  flaps  (depending  on  their  situation)  may  be  of  the  double- 
pedicled  bridge  variety,  or  the  pedicle  may  be  single,  with  attachment 
above  or  below. 


Fig.  777. — Contracture  of  the  hand,  continued. — -i  and  2.  Taken  one  year  after  the 
implantation  of  the  pedunculated  flap.  Note  the  relief  of  the  contracture  and  the  ability 
to  extend  the  thumb.  3.  Taken  two  and  a  half  years  after  operation.  The  flap  has 
flattened  out  completely  and  is  soft  and  resistant.  The  function  of  the  hand  is  practically 
normal. 

W.  T.  Bull,  in  1888,  used  the  same  bridge  flap  for  covering  the 
dorsum  and  palm.  He  placed  the  denuded  hand  under  a  long  bridge 
flap  raised  from  the  chest  wall,  keeping  the  palmar  surface  from  ad- 
hesion to  the  underlying  tissues  by  gauze  (rubber  protective  or  par- 


FiG.  778.  Fig.  779.  Fig.  780. 

Single-pedicled  flap  to  repair  defects  of  the  palm  of  the  hand. 

Fig.   778. — From  thoracic  wall.  Fig.   779. — From  the  abdominal  wall. 

Fig.   780. — ^From  the  opposite  forearm. 

affined  linen  are  preferable).  After  12  days  the  lower  end  of  the  flap 
was  divided  and  folded  around  the  hand  to  cover  the  palmar  surface,, 
and  1 2  days  later  the  upper  pedicle  was  cut  and  used  to  cover  the  rest 
of  the  uncovered  area.     This  method  with  modifications  is  well  worth 


66o 


PLASTIC    SURGERY 


considering.  In  my  own  work  I  prefer  the  gradual  division  of  the 
pedicle  in  cases  where  the  flap  is  so  long. 

Utilization  of  Metacarpal  Bones  in  Formation  of  Movable  Stumps. 
— In  lacerated  and  crushing  wounds  of  the  hand  every  particle  of 
tissue  should  be  conserved.  A  useful  hand  may  be  fashioned  out  of 
very  unpromising  material. 

The  thumb  is  the  most  useful  digit,  and  Klapp  was  able  to  make  a 
good  working  stump  after  traumatic  amputation  of  the  metacarpo- 


PiG.  781. — The  effect  of  transplantation  of  a  pedunculated  flap  from  the  abdomen  into 
an  area  from  which  the  scar  tissue  had  not  been  completely  reraoved.  The  operation  was 
done  several  years  before  the  patient  came  under  my  care.  The  condition  of  the  flap  on 
the  outer  side  of  the  thumb  and  wrist  was  excellent,  but  the  scar  tissue  beneath  it  has 
interfered  with  the  growth  of  the  thumb  and  with  its  function.  Better  function  was  ob- 
tained by  excision  of  the  scar  tissue  at  each  end  and  shifting  the  position  of  the  flap. 

phalangeal  joint.  He  separated  the  metacarpal  bone  of  the  thumb  by 
dividing  the  tissues  between  it  and  the  adjacent  metacarpal  bone,  and 
covered  the  surfaces  with  skin  flaps.  This  skin  may  be  obtained  from 
the  neighborhood  or  from  a  distance. 

Lyle  made  a  short  useful  thumb  in  the  same  way  after  covering  the 
raw  surface  of  a  denuded  hand  with  an  abdominal  flap. 

It  is  advisable  to  suture  the  tendons  over  the  ends  of  the  metacar- 
pals when  amputation  has  been  necessary,  as  in  this  way  better  motion 
is  assured. 

Burkhard  carried  Klapp's  procedure  further.     In  addition  to  the 


SUKGEKY  OF  THE  EXTREMITIES 


66l 


formation  of  a  thumb  stump,  in  a  case  in  which  all  the  fingers  had  been 
destroyed  down  to  the  metacarpophalangeal  articulations,  he  made 
three  movable  stumps  by  cutting  down  between  the  metacarpals 
and  covering  all  raw  surfaces  with  sound  skin.     In  these  operations 


Fk;.  782.  Fig.  783.  Fk,.  784. 

The  use  of  pedunculated  flaps  to  repair  defects  on  the  back  of  the  hand. 
Fig.   782.— Morestin's  method. 

Pig.   783. — A  single  flap  with  pedicle  above,  from  the  thoracic  wall. 
Pig.   784. — A  double-pedicled  flap  from  the  thoracic  wall. 

care  should  be  taken  to  avoid  injuring  the  thenar  muscles.  In  this 
way  a  thumb  stump  may  be  formed  which  can  be  approximated  with 
the  uninjured  fingers,  or  with  other  stumps,  and  will  go  to  make  a 
fairly  useful  hand. 


Pig.  785.  Fig.  786.  Fig.  787. 

Single  and  double-pedicled  flaps  from  the  back  and  buttock  to  repair  defects  in  the  palm 

of  the  hand. 
Fig.   785, — A  double-pedicled  flap  from  the  buttock. 
Pig.    786. — A  single-pedicled  flap  from  the  back. 
Pig.    787. — A  double-pedicled  flap  from  the  buttock. 

The  Use  of  Free  Bone  Grafts  and  Pedunculated  Flaps  of  Skin  to 
Form  Opposition  Finger  Stumps.^ — In  two  cases  in  which  the  thumb 
was  intact  but  where  all  the  fingers  and  metacarpal  bones  had  been 


^62 


PLASTIC    SURGERY 


destroyed,  Albee  was  able  to  construct  an  opposition  stump  which 
changed  a  useless  extremity  into  a  useful  one. 


Fig.  788. — Contracture  following  a  third  degree  burn.  Four  years  duration. — i  and 
2.  Note  the  limit  of  extension.  3.  Result  five  years  after  whole-thickness  grafting.  The 
function  of  the  hand  is  perfect.      Note  the  fingers,  thumb  and  palm.. 


Fig.  789. — Contracture  of  the  back  of  the  hand  following  a  burn.  Duration  four 
months. — i.  The  extent  of  flexion.  It  can  be  seen  that  the  scar  tissue  on  the  back  of  the 
hand  and  fingers  prevents  function.  The  scar  was  excised  and  the  denuded  area  wasj 
covered  with  a  whole-thickness  graft.  2.  The  graft  occupying  the  upper  half  of  the  bad 
of  the  hand,  and  the  proximal  phalanges  of  the  fingers.  The  photograph  has  been  trimmed 
too  closely  on  the  radial  side  to  show  the  extent  of  the  graft  over  the  knuckle  of  the  fore-j 
tfinger.  Photographs  in  2  and  3  were  taken  two  years  after  grafting.  3.  A  fist  can  be 
made  without  difficulty,  and  function  has  been  restored.  The  patient,  who  is  a  presser  bj 
trade,  has  been  able  to  continue  his  work  since  discharge  from  the  hospital  eight  years  ago^ 

In  one  case  a  folded  pedunculated  flap  from  the  chest  wall  suppliec 
the  soft  parts,  and  four  weeks  later  the  pedicle  was  cut  from  the  chest 


SURGERY  OF  THE  EXTREMITIES 


663 


and  a  tunnel  was  made  through  the  flap  down  to  the  os  magnum.  A 
tibial  graft  was  then  driven  into  a  mortise  in  the  os  magnum  and  the 
soft  parts  were  closed  over  it.     In  the  other  case  the  flap  was  obtained 


123  4 

Fig.  790. — Contracture  of  the  hand  folio wnng  a  burn.  Duration  one  year. — i  and  2. 
Plaster  casts  showing  the  condition  before  operation.  Xote  the  absolute  helplessness  of 
the  hand.  3  and  4.  Taken  twenty-two  months  after  the  relief  of  the  contracture  and  the 
transplantation  of  whole-thickness  g:rafts.  Compare  the  positions  of  the  fingers  with  those 
before  operation.  The  function  is  excellent.  Note  in  4  the  large  size  of  the  graft  occupying 
the  entire  back  of  the  hand.  This  case  could  also  have  been  successfully  treated  by  means 
of  a  pedunculated  flap  from  any  suitable  locality. 

from  the  shoulder  and  the  bone  from  the  clavicle.  The  formation 
of  the  soft  parts  and  the  bone  transplantation  being  done  at  the  same 
time.     The  bone  was  driven  into  a  mortise  in  the  stump  of  the  third 


Fig.  791. — Method  of  rebuilding  a  hand  (Burkard). — r.  The  stump  of  the  hand  left 
after  destruction  of  the  thumb  and  fingers  by  freezing.  2.  Finger-like  stumps  formed  from 
the  metacarpal  bones  covered  with  skin. 

metacarpal  bone,  and  the  flap  was  sutured  around  it.  About  four 
weeks  later  the  pedicle  was  cut  from  the  shoulder  and  the  stump  was 
shaped. 


664 


PLASTIC    SURGERY 


The  results  in  the  short  time  which  has  elapsed  since  the  operations 
were  done  have  been  good,  and  a  useful  hand  has  been  provided  in 
each  case.  It  is  too  early  to  determine  whether  the  active  function 
in  this  situation  will  prevent  atrophy  of  the  bone.  Ordinarily  a  bone 
transplant  in  contact  with  bone  at  one  end,  and  extending  into  the  soft 
parts,  without  special  function,  will  eventually  be  absorbed. 

Should  the  ultimate  result  in  these  cases  be  satisfactory,  there  is 
no  reason  why  the  same  procedure  should  not  be  employed  to  form 
a  thumb  stump  to  oppose  any  finger  or  fingers  which  are  intact. 


I  2  3  i 

Pig.  792. — Misplacement  of  the  little  finger  and  ulnar  deflection  of  the  hand,  following  I 
a  burn  of  many  years  duration. — i.  Note  the  position  of  the  hand  and  little  finger.  X-ra\' 
showed  that  the  condition  of  the  joint  precluded  the  restoration  of  function  of  the  finger. 
2  and  3.  The  skin  of  the  finger  was  preserved  as  a  pedunculated  flap  after  removal  of  the, 
phalangeal  bones,  and  was  used  to  fill  in  the  defect  after  relaxing  the  tightly  drawn  scar 
from  the  ring  finger  to  the  wrist.  A  transverse  incision  was  made  across  the  wrist  and  this! 
defect  was  filled  with  a  whole-thickness  graft.  The  lower  margin  of  the  photograph  3 
passes  through  the  lower  portion  of  the  graft.  Function  is  much  improved  and  the  hand 
is  gradually  assuming  a  more  normal  position. 


THE  FINGERS  ! 

Loss  of  Substance.— Skin  grafts  may  be  used  with  great  satisfac- 
tion in  certain  instances.  For  extensive  loss  of  soft  parts  of  the  thumb 
or  finger  without  bone  destruction,  bridge  flaps  (Haubold  and  others) 
have  been  used,  and  later  the  size  of  the  finger  reduced  by  trimming 
operations.     A  single-pedicled  flap  may  also  be  used  for  this  purpose. 

Flaps  from  Injured  or  Contracted  Fingers. — Following  certain  fresh 
wounds  the  injury  to  the  bones  of  one  or  more  fingers  may  be  obviously 


SURGERY  OF  THE  EXTREMITIES  665 

such  that  after  healing  is  complete  the  finger  would  be  useless.  In 
these  cases  a  flap  of  good  skin  of  considerable  size  may  often  be  obtained 
by  removing  the  bone  and  saving  all  the  viable  skin  covering  the  hnger. 
By  the  utilization  of  such  a  flap  a  more  stable  healing  will  be  obtained 
and  quite  extensive  losses  of  substance  may  be  covered,  thus  giving  a 
firmer  and  quicker  healing,  and  preventing  the  formation  of  scar  tissue. 
A  similar  procedure  may  be  carried  out  when  the  wound  is  granulating. 
I  have  taken  advantage  of  this  method  in  utilizing  the  normal  skin  on 
fingers  which  were  so  distorted  by  contracture  as  to  make  their  replace- 
ment impossible. 

Method  of  Lengthening  the  Finger  by  the  Stimulation  of  Granula- 
tions in  a  Celluloid  Tube. ' — It  is  often  possible  to  add  length  to  the 
terminal  phalanx  after  loss  of  tissue  in  finger  injuries,  and  I  have  found 
a  celluloid  tube  useful  for  this  purpose. 

When  a  partial  traumatic  amputation  of  the  terminal  phalanx 
of  a  finger  takes  place,  one  of  two  conditions  is  found:  either  the  part 
is  cut  away  clean  with  little  damage  of  the  remaining  portion,  or  the 
part  is  crushed  off,  and  the  tissues  adjacent  to  the  amputated  portion 
are  more  or  less  traumatized. 

After  the  ordinary  healing  by  granulation,  we  frequently  find  a 
sensitive  stump,  the  bone  being  covered  only  by  a  thin  scar.  The 
question  arises  as  to  the  best  method  of  early  treatment,  especially 
when  the  bone  is  exposed. 

In  order  to  obtain  a  good  functional  result  we  must  contrive  to 
place  a  pad  of  tissue  over  the  bone.  This  may  be  done  rapidly  and 
satisfactorily  by  shortening  the  exposed  bone  and  closing  the  soft  parts 
over  it,  but  this  method  gives  a  shorter  stump. 

In  certain  occupations  the  loss  of  all  or  a  portion  of  the  terminal 
phalanx  of  a  finger  is  a  matter  of  considerable  economic  importance  to 
the  skilled  worker.  It  is  often  advisable  to  preserve  the  remaining 
length  of  the  finger,  and  if  possible  to  replace  the  loss  of  tissue,  thus 
giving  a  more  useful  and  less  painful  stump,  and  at  the  same  time  one 
which  is  less  disfiguring. 

One  should  always  replace  the  amputated  portion  unless  it  is  too 
much  traumatized,  or  unless  more  than  three  or  four  hours  have  elapsed 
between  the  time  of  the  accident  and  the  first  treatment.  This  pro- 
cedure is  attended  with  little  danger,  and  if  the  replaced  portion  does 
not  regain  its  vitality  it  can  be  easily  removed,  and  the  building  up 
process  then  inaugurated. 

'  Davis,  J.  S.,  "Jour.  Amer.  Med.  Assn.,"  May  15,  1915,  1647. 


666 


PLASTIC    SURGERY 


The  majority  of  the  patients  with  these  injuries  are  treated  in  the 
out-patient  department.  Hence  the  use  of  pedunculated  flaps  from 
the  thoracic  or  abdominal  wall  was  contraindicated,  and  a  method  had 
to  be  used  which  would  give  good  results  without  necessitating  ad- 
mission to  the  hospital. 

The  most  promising  procedure  seemed  to  consist  in  stimulating  the 
growth  of  granulation  tissue  on  the  end  of  the  stump,  and  in  some  way 
to  confine  the  growth  to  the  desired  size  and  direction.  After  a  number 
of  experiments  I  found  that  a  sheet  of  celluloid  3^^oo  iiich  thick  would  be 
best  for  the  purpose.     This  material  was  sufficiently  rigid,  transparent, 


I  234 

Pig.  793. — Use  of  the  celluloid  tube  in  lengthening  the  end  of  the  terminal  phalanx. — 
I.  A  convenient  pattern  by  which  to  cut  the  celluloid.  2.  The  celluloid  rolled  into  a  tube. 
3.  The  tube  in  place,  partially  filled  with  a  blood  clot;  patient  seen  shortly  after  the  acci- 
dent. 4.  After  removal  of  the  tube;  the  line  of  the  amputation  can  be  seen,  and  above  it 
the  moulded  clot.  Note  the  snug  fit  of  the  tube  in  3,  and  the  clearness  with  which  the  skin 
can  be  seen  through  it. 

non-adherent,  and  could  be  cut  in  a  shape  which  when  rolled,  formed 
a  tube  adjustable  to  the  size  of  the  finger. 

G.  W.  Meil  advised  in  partial  traumatic  amputation  of  the  termi- 
nal phalanx  that  the  granulations  be  stimulated  and  then  molded  by 
means  of  adhesive  plaster,  but  this  material  has  proved  much  less 
satisfactory  than  the  celluloid  tube. 

Technic. — The  stump  is  painted  with  tincture  of  iodin.  The 
shaped  piece  of  celluloid,  after  being  soaked  in  mercuric  chlorid,  i 
to  1000,  for  a  sufficient  time,  is  sponged  off  with  ether  or  alcohol.  It 
is  then  wrapped  around  the  finger  and  secured  with  narrow  adhesive 
strips,  thus  making  a  tube  which  is  slightly  smaller  at  its  free  end  than 
at  its  base.  When  the  tube  is  properly  adjusted,  it  will  hug  closely 
the  edge  of  the  wound,  and  will  gradually  become  larger  until  it  im- 
pinges on  the  first  interphalangeal  joint.     The  celluloid  may  extend 


SURGERY  OF  THE  EXTREMITIES 


667 


as  far  beyond  the  finger  tip  as  is  needful,  and  in  addition  to  its  primary 
function  it  also  serves  as  a  splint  for  the  finger,  and  as  a  protection  to 
the  wound  (Figs.  793-795). 

In  cases  seen  early,  a  blood  clot  is  allowed  to  form  in  the  tube. 
This  clot  serves  as  a  scaffold  for  granulations.     If  the  soft  parts  are 


Pig.  794. — I.  Finger  stump  four  days  after  the  accident,  before  application  of  the  cellu- 
loid tube.  2.  Finger  ten  and  one-half  months  after  the  accident.  The  heaUng  was  com- 
plete in  thirty  days.     The  arrow  indicates  the  injured  finger. 

lacerated    and   spread   apart,   they  are  gathered  together  and  held  in 
place  by  the  tube. 

In  cases  seen  after  the  granulations  have  started,  every  effort  is 
made  to  stimulate  their  s;rowth,  and  to  train  this  growth  alonsf  the  tube. 


I  2  3 

Fig.  795. —  I.  Three  days  after  the  accident,  note  the  clot.  2.  End  view  of  finger  stump. 
3.  Fourteen  months  after  the  accident.  The  wound  was  healed  in  thirty-five  days.  The 
arrow  indicates  the  injured  finger. 

Any  desired  medication  may  be  applied  to  the  wound  after  the 
celluloid  is  in  place,  either  by  pouring  it  into  the  tube,  or  by  packing  the 
tube  with  gauze.  The  dressing  in  this  way  comes  in  contact  with  the 
wound,  and  is  confined  by  the  tube.  A  loose  gauze  plug  is  then  placed 
in   the  mouth  of  the  tube,  and  over  all  a  small  dressing  secured  by  a 


668 


PLASTIC    SURGERY 


bandage.     In  order  to  give  an  idea  of  the  types  of  cases  treated,  I  will 
include  a  summary  of  the  first  15  cases  treated  by  this  method. 

Summary.' — Number:  15  cases,  males,  13 ;  females,  2.  Ages:  from  16 
to  50  years.  Color:  white,  13;  colored,  2.  Occw^a^zow;  operators  on 
machines,  15.  Etiology:  all  were  injured  by  machines.  Situation: 
right  forefinger,  5;  left  forefinger,  4;  right  middle  finger,  2;  left  middle 
finger,  3;  right  thumb,  i.  Duration  of  lesion  before  coming  under  my 
care:  from  one  hour  to  twenty-six  days.  Amount  lost:  from  0.75  cm. 
(^^0  inch)  of  the  tip,  to  the  entire  terminal  phalanx.     Amount  gained: 


Fig.  796. — The  use  of  a  whole-thickness  graft  over  the  first  interphalangeal  joinx. 
— The  joint  before  grafting  was  covered  with  a  thin  tightly  stretched  scar  following  a 
burn,  which  tore  constantly  when  flexion  was  attempted.  The  scar  was  excised  and  the 
first  figure  shows  the  graft  ten  days  after  transplantation.  The  second  figure  shows  the 
amount  of  flexion  possible,  and  the  condition  of  the  graft  one  year  later. 


from  0.5  to  1.25  cm.  (J-^  to  3^^  inchj.  Type  of  lesion:  the  nail  was 
involved  in  all.  In  2  there  was  some  loss  of  tissue,  the  remaining 
soft  parts  of  the  terminal  phalanx  being  mushroomed  out  and  badly 
crushed,  although  still  attached  to  the  finger  by  pedicles.  In  none 
of  these  was  the  bone  involved.  In  13  the  amputations  were  more  or 
less  clean  cut,  with  little  crushing  of  surrounding  tissues,  and  in  all  the 
bone  was  involved.  In  10  the  lesion  involved  more  of  the  dorsal  than 
of  the  palmar  surface.     In  one  the  skin  was  involved  equally  on  both 


SURGERY  OF  THE  EXTREMITIES  669 

aspects  of  the  finger,  and  in  two  the  lesion  involved  slightly  more  of  the 
palmar  surface. 

Treatment. — The  celluloid  tube  was  used  in  all  in  addition  to 
stimulation.  In  one,  in  addition  to  the  foregoing,  small  deep  grafts 
were  used  to  hasten  healing.  Duration  oj  treatment:  entirely  healed 
after  lo,  21,  24,  26,  28,  29,  30,  34,  35,  36,  38,  39,  45  and  66  days,  with  an 
average  of  ^t,  days.  The  cases  taking  the  greater  number  of  days 
before  healing  was  complete  were  those  in  which  the  wounds  were  seen 
late,  and  which  were  prevented  from  prompt  healing  in  order  to  give 
more  length  to  the  stump. 

Results. — There  was  increase  in  length  of  the  soft  parts  in  all, 
and  in  four  instances  slight  increase  in  the  length  of  the  bone. 

There  was  not  a  single  painful  stump  in  the  series.  The  pad  of 
tissue  over  the  bone  was  quite  movable  and  soft  in  all.  Voluntary 
flexion  of  the  terminal  phalanx  was  excellent  in  all,  even  when  only 
a  small  amount  of  the  phalangeal  bone  remained. 

The  celluloid  tube  has  also  been  used  with  success  as  a  protective 
dressing  for  other  lesions  of  the  terminal  phalanx,  such  as  compound 
fractures,  lacerations,  etc. 

The  method  is  simple,  the  patient  can  return  to  his  home  at  once, 
and  begin  light  work  after  a  short  time.  A  very  small  gauze  dressing 
around  the  celluloid  suffices.  The  granulations  may  be  observed 
through  the  transparent  celluloid  without  removal  of  the  tube.  There 
is  sometimes  sweating  of  the  skin  of  the  finger  if  the  tube  is  allowed 
to  remain  in  place  for  more  than  two  or  three  days.  The  tube  is 
easily  removed,  as  it  does  not  stick,  and  after  being  cleansed  it  may  be 
replaced,  or  a  fresh  tube  adjusted. 

Thickness  of  the  granulating  area  can  be  stimulated  in  various 
ways.  As  the  granulations  grow,  the  epithelium  from  the  skin  edge 
also  grows,  and  often  it  is  difficult  to  prevent  it  from  closing  over  the 
stump  before  the  desired  length  is  obtained.  In  these  instances  the 
epithelial  edges  should  be  kept  down  with  silver  nitrate. 

In  some  cases  when  the  granulations  are  sufficiently  advanced, 
it  is  advisable  to  cover  them  with  small  deep  grafts,  in  order  to  give  a 
more  stable  and  quicker  healing.  In  my  own  series  I  might  have  done 
better  had  I  grafted  more.  The  cases  seen  soon  after  the  accident 
gave  the  best  results,  as  far  as  an  increase  in  length  was  concerned. 

Building  new  tissue  on  the  end  of  the  stump  is  slow,  but  in  the  end  it 
will  preserve  the  bone  which  remains  and  cover  it;  it  will  also  often  add 
materially  to  the  length  of  the  stump.      If  the  joint  is  not  implicated 


670 


PLASTIC    SURGERY 


i 


even  a  short  bit  of  terminal  phalangeal  bone  will  form  the  basis  for  a 
shortened  terminal  phalanx,  which  may  be  voluntarily  extended  and  , 
flexed,  and  can  be  used  nearly  as  well  as  an  intact  terminal  phalanx.  ^ 

From  the  standpoint  of  function,  increased  length,  and  improved 
appearance,  the  results  have  been  better  than  with  any  other 
ambulatory  method  with  which  I  am  familiar. 

Method  of  Lengthening  the  Finger  by  the  Use  of  Pedunculated 
Flaps. — As  much  tissue  as  desired  in  lengthening  the  finger,  after  partial 
traumatic  amputation,  may  be  obtained  by  using  a  bridge  or  peduncu- 
lated flap  from  the  abdominal  or  thoracic  wall  (Nicoladini,  Kausch, 
Sievers  and  others),  or  from  the  thigh,  but  the  procedure  is  irksome  and 
long  drawn  out,  and  requires  admission  to  the  hospital.     In  order  to 


Pig.  797. — Contracture  following  a  crush  burn  between  hot  rollers.  Duration  six 
months. — i.  Before  operation.  Note  the  limit  of  extension.  2  and  3.  Twenty-one 
months  after  the  transplantation  of  a  whole-thickness  graft.  Note  the  complete  extension 
and  flexion. 


replace  the  missing  bone  a  piece  of  bone  (Neuhauser)  or  cartilage  may  be 
implanted  under  the  skin,  and  later  transplanted  in  a  pedunculated 
flap  to  the  finger.  In  the  few  cases  in  which  this  is  necessary  my 
preference  is  for  cartilage. 

Contractiures.^ — These  may  vary  from  slight  flexion  of  one  finge: 
to  complete  flexion  of  all  the  fingers,  and  is  often  associated  with 
contracture  of  the  palm.  The  condition  may  be  due  to  scarring  of 
the  skin  alone  without  injury  to  the  tendons,  or  the  tendons  may 
also  be  partially  or  totally  destroyed.  When  the  tendon  is  intact 
multiple  division  of  the  scar  has  been  frequently  tried,  with  or  without 
the  injection  of  fibrolysin,  but  in  my  experience  the  method  is  far  from 
satisfactory. 

I  have  had  very  good  results  with  whole-thickness  grafts  (after 


i 

i 


SURGERY   OF   THE    EXTREMITIES 


671 


Fig.  798. — Contracture  following  a  burn  by  electricity.  Duration  ten  months. — 
I.  Before  operation.  2.  Ten  and  one-half  years  after  grafting.  The  graft  has  been  ex- 
posed to  the  constant  trauma  incident  to  farm  work.  It  has  increased  in  size  as  the  hand 
has  grown  larger,  and  has  preserved  its  own  characteristics.  Hairs  similar  to  those  on  the 
thigh,  from  which  the  graft  was  taken,  are  growing  on  it.  The  graft  is  pigmented  and 
wrinkled,  but  is  soft  and  movable  with  the  surrounding  skin.  The  functional  result  is 
excellent. 


123  4 

Fig.  799. — Partial  syndactylism  due  to  trauma.  Duration  one  year. — i  and  2.  Note 
the  inability  to  separate  the  middle,  ring  and  little  fingers,  and  the  scar  involvement.  3 
and  4.  The  result  of  several  operations  to  deepen  and  widen  the  commissures.  Compare 
the  ability  to  separate  the  fingers  with  that  before  operation.  In  this  case  the  flaps  were 
more  or  less  infiltrated  with  scar  tissue. 


672  PLASTIC    SURGERY 

completely  relieving  the  contracted  scar  and  excising  the  scar  tissue), 
and  with  them  I  have  successfully  covered  as  many  as  four  fingers  and 
the  adjacent  portion  of  the  palm  at  one  time.  By  a  ''successful" 
result  in  these  cases  I  mean  a  result  which  will  stand  the  acid  test  of 
time,  and  in  which  recurrence  will  not  follow  after  the  patient  has  left 
the  hospital.  In  all  of  these  cases  the  fingers  should  be  extended  and 
kept  in  this  position  continuously  until  healing  is  complete,  after  which 
an  apparatus  should  be  worn  at  night  for  several  months. 

A  large  pedunculated  flap  may  be  used  to  cover  the  denuded  flexor 
surfaces  of  several  fingers  after  relief  of  the  contracture  and  excision 
of  the  scar.  The  division  between  the  fingers  is  made  later  after  the 
flap  has  healed  in  place. 

When  the  tendon  is  destroyed,  an  attempt  may  be  made  to  find 
the  ends  and  unite  them  by  one  of  the  methods  previously  mentioned, 
but  in  case  this  is  done  a  pedunculated  flap  should  be  used,  as  the  pad  of 
fat  beneath  will  often  prevent  adhesion. 

The  Correction  of  Flexor  Contractures  by  Multiple  Lateral  Flaps. 
— Morestin  has  described  an  ingenious  method  of  dealing  with  con- 
tracted scars  of  this  type  which  may  be  used  on  the  thumb  and  fingers. 
He  divides  the  scar  in  the  midline  lengthways  from  one  end  to  the  other. 
Then  by  secondary  incisions  from  the  longitudinal  incision  as  the  axis, 
he  makes  small  angular  pedunculated  flaps,  the  free  margin  being  at 
the  longitudinal  incision,  and  the  bases  sometimes  on  the  border  of  the 
free  extremity,  sometimes  at  the  side  of  the  root  of  the  finger,  and  some- 
times on  the  palm.  It  is  not  necessary  that  all  of  these  flaps  should  be 
made  at  first,  but  gradually  as  the  need  becomes  evident  in  extending 
the  fingers. 

In  this  way  a  series  of  lateral  oblique  flaps  are  formed.  By  the 
formation  of  these  flaps  the  finger  is  usually  released  and  can  be 
straightened;  but  if  this  cannot  be  accomplished  any  binding  tissue — 
such  as  the  remains  of  tendons  and  even  the  articular  ligaments — 
should  be  divided  in  order  to  complete  the  extension. 

After  the  finger  has  been  extended  the  flaps  are  shifted  in  as  trans-  ^ 
versely  as  possible,  and  are  superimposed,  those  from  one  side  alternat- 
ing with  those  of  the  other.     After  several  trials  the  best  positions  are 
found  and  the  flaps  secured  by  sutures,  and  the  finger  is  extended  on  a 
splint.     The  small  raw  surfaces  between  the  flaps  soon  heal. 

Joint  motion  should  be  begun  as  soon  as  healing  is  complete.  In 
the  end  voluntary  flexion  cannot  be  completely  carried  out,  but  the 
contraction  of  the  interosseous,  thenar,  and  hypothenar  muscles  begins 


SURGERY  OF  THE  EXTREMITIES  673 

the  movement  of  flexion  of  the  first  phalanx  toward  the  pahii,  and  the 
adjoining  normal  fingers  carry  the  finger  downward  nearly  to  complete 
flexion.  This  does  not  give  strong  flexion,  but  corrects  a  vicious  con- 
tracture and  causes  restoration  of  function  which,  while  not  perfect,  is 
very  acceptable.  Morestin  reports  many  excellent  results.  I  have 
found  this  method  useful,  but  prefer  wdiole-thickness  grafts  for  the 
purpose. 

DUPUYTREN'S  FINGER  CONTRACTION 

In  1 83 1  Dupuytren  definitely  determined  that  the  deformity  which 
he  described,  was  due  to  the  contraction,  shortening  and  thickening  of 
the  palmar  aponeurosis  (the  flexor  tendons  not  being  involved) .  Since 
that  time  this  observation  has  been  frequently  verified. 

The  condition  belongs  to  adult  life,  being  rare  under  30  years  of 
age.  According  to  Keen  several  congenital  cases  have  been  reported, 
and  recently  Greig  has  reported  such  a  case,  but  personally  I  have 
never  had  the  opportunity  to  see  one.  It  occurs  more  frequently 
in  males,  and  one  or  both  hands  may  be  effected.  The  degree  of  de- 
formity may  be  much  more  marked  in  one  hand  than  in  the  other; 
in  fact  the  disease  may  be  well  developed  for  years  in  one  hand  before 
it  begins  in  the  other.  Bilateral  involvement  is  generally  the  rule. 
When  only  one  hand  is  involved,  it  is  more  apt  to  be  the  right  than  the 
the  left.  Of  183  cases  collected  by  Keen  the  right  hand  only  was 
involved  in  58,  the  left  in  23,  both  hands  in  102. 

Any  one  of  the  fingers  may  be  involved  alone,  but  the  thumb  and 
forefinger  are  most  often  immune.  The  ring  finger  is  the  one  most 
frequently  attacked,  after  which  comes  the  little  finger,  and  next  in 
order  the  middle  finger. 

Nichols  reports  that  in  263  cases  (204  of  Keen's,  and  59  of  his  own) 
there  were  572  fingers  affected  as  follows:  12  thumbs,  24  forefingers, 
93  middle  fingers,  194  little  fingers,  and  249  ring  fingers. 

When  the  condition  is  limited  to  one  hand  the  fingers  involved  are 
usually  adjoining,  but  if  both  hands  are  involved  the  lesions  are  not 
necessarily  symmetrical.  Heredity  seems  to  have  some  etiological 
significance,  a  family  history  of  similar  trouble  being  obtainable  in 
about  20  or  2^  per  cent,  of  the  cases. 

The  onset  is  insidious  and  without  pain.     The  first  thing  noticed 

is  a  flattened  nodular  induration  of  the  palmar  fascia,  in  or  just  above 

the  transverse  crease  in  the  palm  of  the  hand.     The  skin  is  not  adherent 

to  the  nodule  in  the  early  stages,  but  later  the   fascia  bands  which 
43 


674  PLASTIC    SURGERY 

normally  are  attached  to  the  skin  become  thickened  and  contracted, 
so  that  a  puckered  dimple  is  formed,  from  which  a  thickened  band  of 
fascia  can  be  felt  extending  toward  the  finger.  The  thickening  of  the 
fascia  increases,  and  on  the  finger  the  lateral  processes,  as  well  as  the 
central  portion  of  the  digital  fascia,  are  involved.  The  fascia  extending 
upward  toward  the  annular  ligament  of  the  wrist  also  becomes  thick- 
ened, and  there  occurs  a  progressive  gradual  flexion  of  the  finger  or 
fingers  toward  the  palm  of  the  hand.  Ultimately  this  flexion  may 
become  so  marked  as  to  render  the  hand  practically  useless.  It  is 
interesting  that  there  is  seldom,  if  ever,  any  sign  of  an  inflammatory 
process  in  the  development  of  this  condition. 

Etiology. — Many  surgeons,  among  them  Dupuytrer  himself,  believed 
the  disease  to  be  due  to  local  trauma.  Others  have  attributed  it  to  gout 
or  rheumatism,  and  still  others  have  thought  it  to  be  of  nervous  origin. 

Robert  Abbe  has  described  Dupuytren's  contraction  associated  with 
neuralgias  radiating  from  the  seat  of  the  contraction  along  the  arm 
through  the  branches  of  the  brachial  plexus.  The  pain  might  very 
well  be  caused  by  the  pressure  of  a  cervical  rib,  and  the  theory  has 
recently  been  advanced  that  Dupuytren's  contraction  is  always  due  to 
this  cause.  This  may  be  true  in  some  instances,  but  in  the  vast  ma- 
jority of  cases  of  cervical  rib  Dupuytren's  contraction  is  not  present. 
F.  H.  Baetjer  tells  me  that  approximately  50  per  cent  of  all  cases  of 
cervical  rib  are  bilateral,  and  that  of  the  other  50  per  cent  (unilateral) 
about  one-half  show  rudimentary  outgrowths  on  the  other  side.  I 
have  often  seen  atrophy  of  the  muscles  of  the  thenar  and  hypothenar 
group  in  patients  with  cervical  ribs,  but  have  not  yet  observed  Du- 
puytren's contraction  where  cervical  ribs  are  known  to  exist.  In 
fact,  since  this  theory  was  brought  to  my  attention,  I  have  had  a:-ray 
plates  taken  of  several  patients  with  bilateral  Dupuytren's  contraction, 
and  in  none  of  them  have  cervical  ribs  been  found. 

Probably  no  one  of  these  factors  holds  for  all  cases.  Quite  often 
it  would  seem  that  long-continued  slight  trauma  has  a  definite  influence, 
although  in  many  reported  instances  trauma  can  apparently  be  definitely 
excluded,  and  other  causes  must  be  sought.  As  a  matter  of  fact  it 
must  be  acknowledged  that  often  the  etiology,  in  a  given  case,  is  quite 
obscure. 


TREATMENT 

In  all  operative  procedures  for  the  relief  of  Dupuytren's  contraction, 
the  hands  should  be  thoroughly  prepared  by  one  of  the  methods  previ- 


i 


SURGERY  OF  THE  EXTREMITIES  675 

ously  described,  and  asepsis  should  be  preserved  until  the  healing  is 
complete.  An  Esmarch  bandage  is  advisable  in  order  to  have  a  blood- 
less field  for  operation.  Absolute  hemostasis  is  essential.  General 
anesthesia  is  usually  necessary,  but  on  several  occasions  I  have  done 
extensive  excisions  of  the  palmar  fascia  after  blocking  the  nerves  at 
the  wrist  with  a  i  per  cent  solution  of  novocain.  In  very  advanced 
cases  of  long  standing  amputation  of  the  little  and  ring  fingers  may  be 
necessary.  Splints  and  apparatus  for  continuous  extension  may  pos- 
siblv  be  of  some  slight  use  if  applied  systematically  very  early  in  the 
course  of  the  disease,  but  these  are  absolutely  without  value  later,  and 
should  only  be  used  in  the  post-operative  treatment.  As  a  general; 
rule,  after  operation  the  fingers  should  be  extended  on  a  splint  system- 
atically for  at  least  three  weeks,  and  then  at  night  for  several  months. 

Dupuytren's  Operation. — A  transverse  incision  about  2.5  cm.  (i 
inch)  long  is  made  opposite  the  metacarpophalangeal  articulation^ 
dividing  the  skin  and  the  thickened  fascia.  Care  must  be  taken  not  to 
injure  the  flexor  tendons.  If  the  finger  cannot  be  extended  after  this 
incision,  another  may  be  made  opposite  the  articulation  of  the  first 
and  second  phalanges,  and  if  these  are  not  sufficient  as  many  trans- 
verse incisions  through  the  skin  and  fascia  as  seem  necessary,  until 
complete  extension  is  possible.  The  wounds  are  dressed  with  silver 
foil,  boric  ointment,  or  in  some  other  way  appropriate  to  the  particular 
case.  The  fingers  should  be  extended  on  a  splint  which  is  allowed  to 
remain  until  the  wounds  are  completely  healed,  or  for  about  three 
weeks.  After  this  the  splint  may  be  removed  in  the  day  time,  but 
should  be  reapplied  and  worn  at  night  for  several  months.  Slight  mas- 
sage and  passive  motion  should  be  begun  after  two  weeks,  the  manip- 
ulations being  gradually  increased  until  the  voluntary  motions  are 
normal. 

Adams'  Operation. — A  tine  tenotome  is  inserted  between  the  skin 
and  the  fascia  bands  at  points  where  the  skin  is  not  closely  adherent 
to  the  fascia.  The  knife  is  turned  and  the  fascia  bands  are  divided  from 
without  inward  by  a  sawing  motion.  Care  must  be  taken  not  to 
injure  the  flexor  tendons.  These  divisions  may  be  made  in  as  many- 
places  as  necessary  to  loosen  the  finger  freely,  and  to  allow  full  exten- 
sion. Sometimes  as  many  as  ten  or  twelve  divisions  may  be  necessary. 
Any  selected  dressing  may  be  applied  and  the  fingers  then  extended 
on  a  splint.  The  subsequent  treatment  should  be  much  the  same  as 
that  following  Dupuytren's  operation. 

These  two  operations  are   the  simplest,   and  sometimes  are  per- 


676 


PLASTIC    SURGERY 


manently  successful,  but  in  my  opinion  this  success  is  largely  due  to  a 
vigorous  after-treatment.  If  this  is  omitted  recurrence  is  likely. 
In  some  instances,  when  the  physical  condition  contraindicates  more 
extensive  procedures,  one  or  the  other  of  these  operations  should  be 
done. 

Multiple  Transverse  Division  of  the  Fascia  Through  an  Open 
Longitudinal  Incision. — This  procedure  is  advised  by  Hardie,  Kocher, 
Keetley,  and  others. 

A  longitudinal  incision  is  made  over  the  contracted  band,  and 
the  skin  is  separated  from  the  fascia  as  completely  as  possible.  The 
fascia  band  is  divided  transversely  as  many  times  as  may  be  required. 
The  skin  is  closed  with  horse-hair,  and  the  wound  dressed  aseptically. 


Pig.  800. — Operation  for  Dupuytren's  contraction. — The  V-shaped'incision  with'sub- 
sequent  closure.  It  is  seldom,  except  in  the  earliest  cases,  that  the  skin  can  be  closed 
in  this  manner.  If  the  contraction  is  of  long  standing  and  the  skin  is  much  involved,  a 
large  portion  of  the  defect  cannot  be  closed  by  suture,  and  skin  grafting  is  necessary. 

The  fingers  are  extended  on  a  splint  which  should  be  worn  for  three 
weeks.  Massage,  passive  motion  and  a  splint,  at  night  only,  for  several 
months  constitute  the  subsequent  treatment. 

Recontracture  may  occur  later,  but  this  is  a  better  procedure 
than  either  Dupuytren's  or  Adams'  operation. 

Excision  of  the  Contracted  Fascia. — It  is  impracticable  to  excise 
the  palmar  fascia  completely,  but  large  areas  may  be  removed  without 
difficulty.  Operations  based  on  this  principle  are  certainly  rational, 
and  give  the  best  ultimate  results.  Excision  of  the  thickened  fascia 
through  a  longitudinal  incision  gives  better  results  than  a  simple 
division  of  the  band  in  several  places  through  a  similar  incision. 
The  fascia  may  be  taken  out  through  a  V-shaped  incision,  the  apex  of 


SURGERY  OF  THE  EXTREMITIES 


677 


which  is  about  the  level  of  the  transverse  palmar  crease,  with  the  base 
a  little  above  the  root  of  the  affected  finger.  The  incision  is  carried 
down  through  the  fascia,  and  the  flap  of  skin  and  fascia  is  lowered. 
After  the  linger  (or  fingers)  has  been  straightened,  the  contracted  fascia 
is  removed,  and  the  skin  is  closed  if  possible.  This  is  not  often  practi- 
cable, as  the  puckering  of  the  skin  and  its  infiltrated  condition  prevent 
satisfactory  closure.     If  defects  are  left,  they  may  be  grafted. 

In  some  instances  the  involvement  of  the  skin  is  so  marked  that  it 
is  useless  to  attempt  suturing,  and  in  these  cases  I  have  found  it  better 
to  excise  the  skin  completely,  and  either  graft  with  a  w'hole-thickness 
graft,  or  to  apply  a  pedunculated  flap  from  the  abdomen.     Where  the 


D 


Fig.  801. — Griffith's  operation  for  Dupuytren's  contraction  {Binnie). — i.  The  con- 
tracted palmar  fascia  is  excised  through  the  incision  AB.  Then  the  flaps  E  and  P  are  made 
by  the  curved  incisions  AD  and  BC  and  are  raised.  2.  The  free  end  of  the  flap  E  is  turned 
so  that  it  covers  the  raw  surface  left  by  the  reflexion  of  the  end  of  the  flap  F,  and  the  end 
of  the  flap  F  covers  the  raw  surface  left  by  the  reflection  of  the  flap  E. 

skin  is  much  involved  operations  utilizing  flaps  from  the  palm  cannot  be 
successfully  carried  out. 

It  may  be  advisable  to  do  a  combination  operation  in  stages. 
For  instance,  we  can  make  a  division  of  the  fascia  by  one  of  the  methods 
previously  described,  which  will  allow  extension,  and  follow  this  after 
healing  is  complete  with  a  more  radical  procedure.  A  modification  of 
Griffith's  operation  may  be  of  use  in  selected  cases  as  follows :  Reflect 
the  flaps  as  described  in  the  diagram  at  once  and  excise  the  fascia, 
instead  of  trying  to  excise  it  through  the  longitudinal  incision  AB, 
as  advised  by  Grifiith.  Then  shift  the  flaps  as  shown  in  the  diagram. 
This  method  is  contraindicated  in  cases  in  which  the  skin  is  thin  and 
much  involved  (Fig.  8oi). 

Lotheissen's  Operation. — A  curved  incision  is  made  extending 
from  the  middle  of  the  ulnar  side  of  the  first  phalanx  of  the  little 
finger  down  to  the  ulnar  side  of  the  palm  and  across  just  above  the 
wrist  to  the  base  of  the  thenar  eminence.     The  flap  is  reflected,  the 


678 


PLASTIC    SURGERY 


fascia  is  excised  and,  after  the  fingers  have  been  extended,  the  flap  is 
sutured  in  position.  There  is  always  a  defect  left  near  the  wrist,  which 
may  be  allowed  to  granulate,  or  may  be  grafted  (Fig.  802). 

Hutchinson,  in  191 7,  advocated  a  new  method.  He  excises  the 
thickened  palmar  fascia  with  the  digital  prolongation  and  closes  the  skin. 
He  then  turns  the  hand  over  and  makes  a  semi-lunar  incision  over  the 
first  interphalangeal  joint,  divides  the  extensor  tendon  and  slightly 
shortens  it.     After  removing  the  head  of  the  first  phalanx  he  sutures  the 

tendon  and  closes  the  skin  wound.  No  splint 
is  used,  but  he  begins  gentle  active  and  passive 
motion  within  a  few  days. 

This  operation  might  be  indicated  in  ex- 
treme cases  in  which  there  was  shortening  of 
the  anterior  and  lateral  ligaments,  but  it  seems 
unnecessary  to  shorten  the  finger  when  an 
equally  good  result  can  be  obtained  by  divid- 
ing the  ligaments  after  proper  excision  of  the 
thickened  fascia.  The  shortening  of  the  ex- 
tensor tendon  is  unnecessary,  as  this  will  soon 
regain  its  original  length  after  the  finger  has 
been  extended  for  a  little  time. 

In  my  own  work  I  have  found  that  the 
best  permanent  results  are  always  obtained 
when  the  thickened  contracted  fascia  is  excised. 
The  approach  varies  with  the  extent  of  the  con- 
tracture. The  condition  of  the  skin  involve- 
ment with  scar  tissue  should  determine  to  what 
extent  it  should  be  utilized  in  closing  the  de- 
fect. Unless  there  is  a  reasonable  chance  of 
success  it  should  be  excised,  and  the  defect  cov- 
ered with  a  graft  of  whole-thickness  skin,  or  with  a  pedunculated  flap 
of  skin  and  subcutaneous  fat,  from  a  distant  part.  The  latter  method 
eliminates  any  pain  which  might  occur  following  the  removal  of  the 
protection  afforded  the  underlying  parts  by  the  palmar  fascia. 

FiBROLYSiN  has  been  used  in  the  treatment  of  Dupuytren's  con- 
traction and  good  results  have  been  reported,  especially  after  its  use 
in  conjunction  with  multiple  transverse  incisions  through  the  con- 
tracted bands.  My  belief  is  that  the  good  results  were  due  in  large 
part  to  the  operation,  and  the  prolonged  post-operative  massage  and 
splinting.     That  the  fibrolysin  has  not  much  effect  is  suggested  by  the 


Fig.  802. — ^Lotheisen's 
operation  for  Dupuytren's 
contraction.  (Binnie).- — The 
curved  incision  ABC  is 
made,  the  skin  is  reflected, 
and  the  thickened  palmar 
fascia  is  excised.  The  fingers 
are  extended  and  the  edges 
are  closed  as  far  as  possible. 
The  raw  area  which  is  usu- 
ally left  may  be  grafted. 


SURGERY    OF    THE    EXTREMITIES 


679 


Fig.  803. —  Dupuytren's  contraction  of  the  little  finger. — i  and  2.  Front  and  side 
views.  This  contraction  was  cured  by  the  complete  excision  of  the  thickened  palmar 
fascia  and  closure  of  the  skin,  after  blocking  the  nerves  in  the  wrist.  There  has  been  no 
tendency  to  recurrence.  The  little  finger  of  the  other  hand  had  also  been  successfully 
operated  upon  by  another  surgeon  several  years  previously. 


Fig.  804. — BiUtteral  Dupuytren's  contractiuu  invulving  the  right  ring  finger  and  the 
left  middle  finger.— Note  the  lumpy  contracted  skin  and  the  prominent  bands  of  tightly 
drawn  fascia.  Much  against  my  judgment  I  was  forced  to  treat  this  patient  by  multiple 
subcutaneous  division  of  the  contracting  bands,  as  it  was  not  possible  for  him  to  enter  the 
hospital.     He  obtained  temporary  relief. 


68o  PLASTIC    SURGERY 

fact  that  equally  good  results  may  be  obtained  from  the  operative 
procedure  alone. 

The  Transplantation  of  Fingers  and  Toes  to  Replace  Fingers 

Recently  Joyce  replaced  a  missing  thumb  by  transplanting  the  ring 
finger  from  the  other  hand,  and  obtained  a  remarkably  good  functional 
result. 

His  method  is  as  follows:  "  (i)  An  incision  is  made  along  the  radial 
border  of  the  hand  beginning  at  a  point  which  corresponds  with  the 
horizontal  level  of  the  center  of  the  web  between  the  index  finger  and 
the  thumb  of  the  sound  hand,  and  somewhat  nearer  the  dorsum  than 
the  palm.  When  the  wrist  is  reached,  the  incision  is  carried  along  the 
radial  border  of  the  forearm  for  a  distance  of  2.75  to  5.  cm.  (13^10  to  2 
inches) .  The  incision  on  the  side  of  the  hand  is  deepened  sufficiently  to 
accommodate  the  new  metacarpal  bone,  care  being  taken  not  to  cut 
across  muscle  fibers.  (In  the  patient  on  whom  the  operation  was 
performed,  a  plane  of  fibrous  tissue  was  found  apparently  filling  up 
the  space  left  by  removal  of  the  metacarpal  bone,  and  in  this  the  bed 
was  made.)  The  articular  surface  of  the  trapezium  is  exposed.  The 
skin  and  superficial  and  deep  fascia  on  either  side  of  the  incision  along 
the  radial  border  of  the  wrist  are  reflected,  the  tendons  of  the  exten- 
sores  secundi  internodii  pollicis,  primi  internodii  pollicis,  ossis  meta- 
carpi  pollicis,  flexor  longus  pollicis,  and  flexor  carpi  radialis  are  defined, 
and  one  of  the  dorsal  cutaneous  branches  of  the  radial  nerve  is  found 
and  divided. 

(2)  An  inverted  V-shaped  incision  is  made  on  the  radial  side  of  the 
ring  finger,  the  apex  of  the  incision  being  placed  midway  between  the 
dorsal  and  palmar  aspects  of  the  finger  at  the  level  of  the  proximal 
interphalangeal  joint.  The  triangular  piece  of  skin  marked  out  by  the 
incision  is  then  reflected  upward.  The  limbs  of  the  incision  are  carried 
obliquely  backward  and  forward  on  to  the  dorsum  and  palm  of  the 
hand,  and  are  deepened  in  order  to  expose  the  extensor  and  flexor 
tendons.  These  are  divided  at  the  extremity  of  the  incisions  and  the 
proximal  ends  prevented  from  retracting  by  suturing  them  to  the  peri- 
osteum and  soft  tissues  covering  the  metacarpal  bone.  The  soft  tissues 
are  now  divided  at  the  base  of  the  proximal  phalanx  on  its  radial, side 
down  to  the  periosteum.  The  digital  vessels  on  this  side  of  the  finger 
are  tied  and  the  distal  end  of  the  collateral  branch  of  the  median 
nerve  is  sought  for  and  identified.     The  extensor  and  flexor  tendons 


SURGERY  OF  THE  EXTREMITIES  68 1 

are  dissected  up  in  a  distal  direction  exposing  the  base  of  the  proximal 
phalanx,  and  a  hole  is  drilled  through  the  base  of  the  bone  and  threaded 
with  a  stout  catgut  suture.  The  linger  is  now  dislocated  from  the 
metacarpal  bone  by  cutting  through  the  ligaments  of  the  metacarpo- 
phalangeal joint.  The  soft  tissues  on  the  ulnar  side  of  the  proximal 
phalanx  are  raised  for  a  short  distance  from  the  periosteum,  the  operator 


Fig.  80s.  Fig.  806. 

The  substitution  of  the  ring  finger  of  the  left  hand  for  a  missing  right  thumb  {Joyce's  case). 
Fig.   805. — The  right  hand  before  operation. 
Fig.    806. — The  two  hands  grown  together,  after  removal  of  the  plaster. 

working  from  the  deep  aspect  and  taking  care  not  to  injure  the  digital 
vessels. 

The  triangular  flap  of  skin  is  now  turned  down  to  cover  the  head 
of  the  metacarpal  bone,  and  the  incisions  on  the  dorsum  and  palm  of 
the  hand  are  sutured  with  fine  catgut  stitches.  The  proximal  end  of 
the  extensor  tendon  is  pulled  over  to  the  palmar  aspect  of  the  hand, 
and  the  ring  finger  is  then  ready  for  grafting  into  its  new  position. 


682 


PLASTIC    SURGERY 


(3)  The  two  hands  are  apposed  in  a  manner  which  is  sufficiently 
indicated  in  the  accompanying  photographs.  This  stage  of  the  opera- 
tion is  nov/  completed  as  follows: 

(a)  The  flexor  tendons  of  the  finger  are  joined  to  the  long  flexor 
of  the  thumb,  if  this  has  been  found,  or  to  the  flexor  carpi  radialis  if 
more  convenient. 

(b)  The  proximal  phalanx  is  anchored  in  its  position  by  stitching 
the  catgut  suture,  threaded  through  its  base,  to  the  scar  tissue  covering 
the  articular  surface  of  the  trapezium  (Figs.  805-809). 


Fig.  807.  Fig.  808. 

Figs.  807  and  808. — (Joyce's  case  continued.) — The  transplanted  ring  finger  in  its  new  position. 

(c)  The  extensor  ossis  metacarpi  pollicis  is  stitched  to  the  perios- 
teum at  the  base  of  the  proximal  phalanx  (new  metacarpal  bone). 

(d)  The  tendons  of  the  extensores  secundi  and  primi  internodii 
pollicis  are  united  and  joined  to  the  extensor  tendon  of  the  finger 
(new  thumb). 

(e)  The  radial  cutaneous  nerve  exposed  in  the  first  stage  of  the 
operation  is  sutured  to  the  collateral  branch  of  the  median  nerve  of  the 
ring  finger. 

(/)  The  skin  incisions  are  sutured.  The  incision  on  the  radial 
border  of  the  wrist  is  sutured  in  a  distal  direction  to  cover  the  base 
the  new  metacarpal  bone  and  the  tendon  unions.     The  dorsal  and 


SURGERY  OF  THE  EXTREMITIES 


683 


palmar  edges  of  the  incision  on  the  radial  border  of  the  hand  are 
sutured  to  the  dorsal  and  palmar  edges  of  the  skin  bordering  the  tri- 
angular raw  area  on  the  radial  border  of  the  ring  finger  (new  thumb). 
Fine  interrupted  catgut  sutures  are  used  throughout  for  the  skin 
stitches. 

The  hands  are  then  fixed  in  the  apposed  position  with  plaster  of 
Paris,  which  is  left  undisturbed  for  four  weeks,  and  is  then  removed. 

(4)  The  final  stage  in  the  operation  consists  in  dividing  the  nutritive 
flap  (two  months  later)  and  separation  of  the  hands,  ligature  of  the 


Fig.   809. —  {Joyce's  case,  continued.) — A-ray  after  transplantation. 


proximal  ends  of  the  ulnar  digital  vessels  of  the  finger  which  has  been 
removed,  and  closure  of  the  raw  areas  which  remain." 

I  have  not  yet  had  an  opportunity  to  try  this  method,  but  it  is 
undoubtedly  rational,  and  ought  to  be  a  satisfactory  procedure. 

Toes  have  been  transplanted  (Nicolodini,  Krause.  Klemm,  Eisels- 
berg,  Horhammer  and  others)  to  take  the  place  of  a  missing  thumb  or 
finger,  but  the  result  is  seldom  worth  the  trouble. 

The  bone  of  a  lost  phalanx  may  be  replaced  by  a  shaped  piece  of 
rib  cartilage  (Morestin,  Soubey-^in  and  Perret).  or  by  a  phalanx  from 


684  PLASTIC    SURGERY 

the  toe  (Wolf,  Goebel  and  others),  or  by  a  free  bone  graft  from  the  tibia 
or  ribs  (Morestin  and  others). 

'      TENDON  INVOLVEMENT 

If  tendons  of  either  extremity  are  involved  in  addition  to  the  skin, 
and  are  tightly  adherent  to  the  scar  and  underlying  tissue,  they  should 
be  carefully  freed,  and  the  fat  of  the  flap  placed  in  such  a  way  that  it 
may  act  as  a  sort  of  channel  for  them.  Passive  motion  should  then  be 
begun  after  ten  days. 

If  a  portion  of  a  tendon  (or  tendons)  is  destroyed  the  scar  connect- 
ing the  ends  may  be  utilized  to  form  the  new  tendon;  the  tendon  may  be 
lengthened  by  the  desired  plastic;  a  new  tendon  may  be  made  of  a 
fascia  tube;  a  free  tendon  transplant  may  be  used,  or  a  silk  tendon 
may  be  made.     In  the  majority  of  these  cases  the  flap  should  be 


^>^ 


-^rr- 


FiG.  8 10. — Simple  methods  of  tendon  lengthening.  The  more  complicated  methods 
give  an  uneven  surface  which  does  not  slide  so  easily,  and  which  makes  the  return  of  func- 
tion slower  and  more  difficult. 

securely  grown  into  its  position,  and  then  the  newly  formed  tendon 
should  be  inserted  in  a  tunnel  made  in  the  fat. 

In  old  cases  the  flexor  tendons  have  sometimes  contracted,  and 
lengthening  is  necessary.  The  simpler  and  smoother  methods  of  divi- 
sion and  suture  are  advisable,  because  function  will  be  more  quickly  re- 
stored. I  prefer  the  use  of  the  fat  from  the  flap  for  the  tendon  channel 
to  that  of  free  fat  transplants. 

Exposed  Tendon 

At  times  we  are  confronted  with  a  wound  on  the  forearm  or  hand, 
or  on  the  ankle  or  dorsum  of  the  foot,  in  which  a  portion  of  one  or  more 
tendons  is  exposed,  the  sheaths  having  been  destroyed.  These  wounds  I 
are  usually  due  to  the  pressure  of  a  plaster  cast  or  to  some  injury  which 
has  caused  destruction  of  the  overlying  soft  parts,  and  left  the  exposed 
tendon  surrounded  by  a  more  or  less  extensive  zone  of  scar  tissue. 
The  exposed  tendon  may  become  partially  or  completely  necrotic, 
and  in  due  time  will  slough.     These  wounds  are  very  sluggish  and  are 


SURGERY  OF  THE  EXTREMITIES  685 

difficult  to  treat  successfully.  They  are  usually  infected  and  must 
first  be  sterilized  with  Dakin's  solution,  or  by  some  other  method  which 
will  give  a  negative  bacterial  count.  The  part  should  be  immobilized 
and  all  portions  of  the  tendon  that  are  unquestionably  necrotic  should 
be  removed.  If  granulation  tissue  does  not  soon  show  a  tendency  to 
cover  the  exposed  tendon,  several  longitudinal  incisions  should  be  made 
in  it  down  to  healthy  tissue.  Usually  granulations  will  soon  appear  in 
the  slits  and,  after  the  removal  of  any  necrotic  tendon  strands  that  may 
appear  between  them,  will  soon  cover  the  tendon.  A  pocket  may  form 
at  either  extremity  of  the  wound,  and  if  this  occurs  the  overlying  tissues 
should  be  removed  and  the  tendon  treated  as  described  above,  or 
excised,  as  seems  best. 

There  is  no  reason  whatever  why  the  entire  thickness  of  the  tendon 
should  not  be  excised  when  it  is  necrotic.  Pro\'ided  that  the  wound  is 
sterile  the  tendon  defect  may  be  immediately  filled  by  a  tendon  plastic ; 
or  the  ends  may  be  secured  and  the  tendon  plastic  done  later  if  neces- 
sary, after  the  wound  has  healed. 

Occasionally  in  narrow  wounds  with  normal  surrounding  skin  the 
edges  may  be  drawn  together  over  the  tendon  after  undercutting,  with 
or  without  relaxation  incisions.  If  this  cannot  be  done,  I  have  found 
that  the  best  method  of  obtaining  a  resistant  painless  closure  is  to  use  a 
pedunculated  flap  from  the  neighboring  skin  or  from  a  distant  part. 
The  granulating  surface  may  be  grafted  with  small  deep  grafts  which 
are  more  likely  to  take  on  a  poor  base  than  the  other  types.  If  the 
result  is  not  stable  and  the  scar  is  adherent  and  resists  loosening,  it 
should  be  excised  and  the  gap  filled  with  a  pedunculated  flap. 

BIBLIOGRAPHY 

Albee,  F.  H.     'Annals  of  Surg.  "  April,  1919,  379. 

Beck,  C.     "New  York  Med.  Jour., "March  25,  1905,  582. 

"Surg.  Clinics."     Chicago,  1917,  i,  345. 
Beck,  E.     "New  Y'ork  Med.  Jour.,"  May  20,  191 1,  988. 
Berger,  p.     "Bull,  de  la  Soc.  de  Chir."     Paris,  1900,  141. 
Bull,  W.  T.     "Trans.  Amer.  Surg.  Assn.,"  1895,  492. 
BuRKHARD,  O.     "Munchen  med.  Wchnschr.,"  Sept.  26,  1916,  1409. 

Croft.     "Medico-Chir.  Trans.,"  1S89,  Ixxii,  349. 

EiSBLSBERG.     "Arch.  f.  klin.  Chir.,"  Bd.  61,  1900. 

FoNTAN.     In  Metin:  "These  de  Lyon,"  1887-88,  107. 

Gill,  A.  B.     ""Anns.  Surg.,"  Jul}-,  1918,  55. 


686  PLASTIC    SURGERY 

Gleiss.     "Deutsche  med.  Wchnschr."     Leipzic.  u.  Berlin,  1916,  xlii,  1562. 
GoEBEL,  W.     "Munchen  med.  Wchnschr.,"  Feb.  18,  1913,  356. 

Hans,  H.     "Med.  Klin.,"  Nov.  21,  1915,  1291. 
Haubold,  H.  a.     "Anns.  Surg.,"  Oct.,  1910,  536. 
HoRHAMMER,  C.     "  Munchen  med.  Wchnschr.,"  1915,  Ixii,  1681. 

Joyce,  J.  L.     "Brit.  Jour.  Surg.,"  Jan.,  1918,  499. 

Kausch.     "Archiv  f.  klin.  Chir.,"  Bd.  74,  1904,  495. 

"Deutsche  med.  Wchnschr.,"  1909,  2146. 

"Deutsche  med.  Wchnschr.,"  191 1,  283. 
Klapp.     "Deutsche  med.  Wchnschr.,"  1912,  1569. 

"Deutsch.  Zeitsch.  f.  Chir.,"  191 2,  cxviii,  479. 
Klemm.     "Arch.  f.  klin.  Chir.,"  1911,  Bd.  96,  181. 

Lyle,  H.  H.  M.     "Anns.  Surg.,"  May,  1914,  767. 

Mayo-Robson,  A.  W.     "Brit.  Med.  Jour."     London,  1918,  i,  257. 
Meil,  G.  W.     "Denver  Med.  Times,"  Jan.,  1910,  273. 
MoRESTiN,  H.     "Bull,  et  mem.  Soc.  de  chir.  de  Par.,"  191 2,  1262. 

"La  Presse  med."     Paris,  Aug.  9,  1913,  655. 

"Rev.  de  Chir."     Paris,  July,  1914,  i. 

"Bull,  et  mem.  Soc.  de  chir.  de  Par.,"  191 7,  580. 
Murphy,  J.  B.     "Surgical  Clinics."     Chicago,  1915,  iv,  11 19. 

Neuhauser,  H.     "Berliner  klin.  Wchnschr.,"  Nov.  27,  1916,  1287. 
NicoLADONi,  C.     "Archiv  f.  klin.  Chir.,"  Bd.  61,  606. 
"Archiv  f.  klin.  Chir.,"  Bd.  69,  695. 

Payr.     "Deutsche  med.  Wchnschr.,"  1910,  781. 
PONCET.     In  Metin:  "These  de  Lyon,"  1887-88,  99. 

QuENU,  E.     "Rev.  de  chir."     Paris,  1916,  xxxv,  20. 
RoCHARD.     "Bull,  de  la  Soc.  de  chir.,"  1902,  53. 

SiEVERS,  R.     "Deutsche  Zeitschr.  f.  Chir.,"  Dec,  1913,  Bd.  120,  35. 
SouBEYRAN  &  Perret.     "Lyon  Med.,"  cxxvi,  191 7,  479. 
Steindler,  a.     "Surg.,  Gyne.  &  Obst.,"  Sept.,  1918,  317. 
Stone,  J.  S.     "Boston  Med.  &  Surg.  Jour.,"  1905,  clii,  246. 

TiETZE.     "Deutsche  med.  Wchnschr.,"  1898,  278. 
TuFfiER.     "Bull,  de  la  Soc.  de  chir,"  1904,  947. 

Vivian,  C.  S.     "Southwestern  Med."     El  Paso,  Texas,  Jan.,  1918,  21. 

Wagner,  W.     "Centralbl.  f.  Chir.,"  June  18,  1887,  27. 
Walcher.     "Deutsche  med.  Wchnschr.,"  Nov.  2,  1916,  1341. 
Walker,  G.     "Johns  Hopkins  Hospital  Bull.,"  1901,  xii,  129. 
Wolff,  H.     "Munchen  med.  Wchnschr.,"  Nr.  11,  191 1,  578. 

Dupuytren's  Finger  Contraction 

Adams,  Wm.     "Contractions  of  the  Fingers,"  2d  Ed.,  1892. 

v.  Bergmann  (Bull).     "System  of  Practical  Surgery,"  1904,  iii,  361. 
BiNNiE,  J.  F.     "Operative  Surgery,"  7th  Ed.,  1916,  1261. 


SURGERY    OF    THE    EXTREMITIES  687 

DuPUYTREN'.     ''Lecons  Oracles,"  i,  1S32,  3. 

Elder,  J.  M.     Bryant  &  Buck:  "'American  Practice  of  Surgery,"  vi,  318. 

Greig,  D.  M.     "Edinb.  Med.  Jour.,"  1Q17,  .xix,  384. 

Griffith,  J.  D.     Quoted  by  Binnie:  "Operative  Surgery,"  7th  Ed.,  p.  1262. 

H.\rdie.  J.     "Med.  Chron."     Manchester,  1884-5,  i,  9. 
Hi'TCHiX-sox.  J.     "Lancet."     London,  Feb.  24,  191 7,  295. 

J.vxssen,  p.     "  .\rchiv  klin.  Chir.."  1902,  l.xvii,  761. 

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"Amer.  Jour.  Med.  Science,"  Jan.,  1906,  23. 
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CHAPTER  XXV 

SURGERY  OF  THE  LOWER  EXTREMITY 

THIGH 

Loss  of  Substance.- — In  the  early  treatment  of  extensive  superficial 
wounds  or  burns  involving  the  crotch  and  adjacent  tissues  it  is  most 
important  that  the  thigh  be  held  in  abduction.  Destruction  of  the 
skin  maybe  due  to  operation,  trauma,  ulceration  (chancroidal,  tubercular 
or  S}^hilitic),  and  burns  of  various  sorts.  If  the  wound  is  fresh,  it 
should  be  immediately  grafted.  Healthy  sterile  granulating  wounds 
should  also  be  grafted. 

AATien  the  granulating  surface  is  surrounded  by  an  old  tightly 
drawn  scar,  or  the  ulcer  is  very  sluggish,  the  area  must  be  completely 
excised  with  a  wide  margin  down  to  healthy  tissue.  The  tension  of 
the  scar  must  also  be  relieved  by  properly  placed  incisions,  or  partial 
excision,  and  the  raw  surfaces  immediately  grafted.  This  holds  for 
the  entire  lower  extremity.  In  this  wa}^  I  have  been  able  to  close 
permanently  ulcers  which  have  existed  for  years. 

When  the  thigh  or  leg  is  completely  covered  with  scar,  ulceration  is 
common  and  is  difficult  to  heal.  Excision,  followed  by  grafting  or  the 
use  of  a  pedunculated  flap,  offers  the  only  method  of  permanent  cure. 
In  those  instances  in  which  the  healing  is  unassisted,  a  break-down  can 
be  confidently  looked  for  in  the  course  of  time. 

Pedunculated  flaps  from  the  neighboring  skin  may  be  used,  if 
normal  skin  is  available,  and  I  have  employed  flaps  from  the  other 
leg  or  thigh  in  these  cases.  By  double  transfer  a  flap  from  the 
abdominal  wall  may  be  implanted  into  the  wrist  or  forearm,  and  then, 
after  flexion  of  the  thigh,  the  pedicle  may  be  cut  from  the  abdomen  and 
this  flap  may  be  transferred  to  it. 

KNEE 

Loss  of  substance  around  the  knee-joint  must  be  covered  with 
flexible  strong  skin  if  unimpaired  function  is  to  be  obtained.  If 
the   defect  is  over  the   anterior  surface,  the  part  should  be  put  up 


SURGERY  OF  THE  LOWER  EXTREMITY 

1 


689 


/    -f^/ 


M 


Fig.  811. — Arteries  of  the  skin  of  the  anterior  portion  of  the  thigh  (Manchot)- — i. 
femoral  artery,  a.  Cutaneous  branches  of  the  femoral  artery.  2.  Profunda  femoris 
rtery.  /3.  Cutaneous  branches  of  the  profunda  femoris.  3.  Superficial^arterial  anas- 
Dmosis  around  the  knee. 


44 


690 


PLASTIC    SURGERY 


Fig.  812. — Arteries  of  the  skin  of  the  buttock  and  posterior  surface  of  the  thigh  (Man- 
chot). — I.  Cutaneous  branches  of  the  gluteal  artery.  2.  Cutaneous  branches  of  the  comes 
nervi  ischiadic!  artery.  3.  Cutaneous  branches  of  the  internal  pudic  artery.  4.  Cuta- 
neous branches  of  the  lateral  sacral  arteries.  ,5.  Cutaneous  branches  of  the  ileo4umbaT 
and  the  last  lumbar  arteries.  6.  Cutaneous  branches  of  the  obturator  artery.  7.  Cuta- 
neous branches  of  the  internal  circumflex  artery.  8.  Cutaneous  branches  of  the  profunda 
femoris  artery.  9.  Cutaneous  branches  of  the  popliteal  artery.  10.  Cutaneous  branches 
of  the  external  circumflex  artery. 


SURGERY    OF    THE    LOWER    EXTREMITY 


691 


Pig.  813. — Arteries  of  the  skin  of  the  popliteal  space  and  posterior  surface  of  the  leg 
(.Manchot) . —  i.  Superficial  median  sural  branches  of  the  popliteal  artery.  2.  Superficial 
lateral  sural  branches.  3.  Superficial  median  branches.  4.  Musculo-cutaneous  branches 
Df  the  deep  sural  arteries. 


692 


PLASTIC    SURGERY 


Fig.  814. — Arteries  of  the  side  of  the  leg  (Manchot). — Cutaneous  branches  of  ti 

posterior  tibial  artery. 


SURGERY    OF    THE    LOWER   EXTREMITY 


693 


ill  partial  flexion;  if  it  be  on  the  posterior  surface,  the  leg  should 
be  extended.  I  have  used  whole-thickness  grafts  around  the  knee 
with  success,  but  have  had  the  best  results  with  pedunculated  flaps. 
These  flaps  may  be  obtained  from  the  same  thigh  or  leg,  or  from  the 


Pig.  815. — Chronic  ulcer,  three  years  duration,  in  an  extensive  tightly  drawn  scar  of  the 
tigli. — I.  This  area  had  never  healed  and  was  extremely  painful.  The  entire  ulcer  with  a 
'de  margin  was  excised  down  to  normal  tissue  and  was  immediately  covered  with  OUier- 
rhiersch  grafts.  2.  The  size  of  the  healed  area  can  be  seen.  There  has  been  no  recurrence 
luring  the  three  years  since  operation,  and  function  is  much  improved. 

>pposite  thigh  or  leg  (^Maas  and  others),  according  to  the  situation 
md  extent  of  the  defect. 

LEG 

Loss  of  Substance.— Skin  grafts,  preferably  of  the  small,  deep, 
31  whole-thickness  variety,  may  be  used  to  cover  defects  of  any  kind 


694 


PLASTIC    SURGERY 


Pig.  8i6. — Method  of  gradual  stretching  of  normal  tissues.  (Morestin). — i.  The 
groin  after  the  excision  of  all  defective  tissues.  Xote  the  sutures  in  position.  2.  The  thigh 
is  flexed  on  the  body  after  the  sutures  are  tied.     3.   The  result  of  gradual  stretching. 


Fig.  817.  Fig.  818. 

Fig.  817.— Method  of  utilizing  a  bridge  flap  from  the  chest  wall  for  covering  a  popliteal 
defect  {v.  Hacker). — This  method  could  only  be  used  in  young  children  and  even  then 
its  advisability  is  doubtful. 

Fig.  8x8. — Method  of  restoring  the  popliteal  space  by  means  of  a  pedunculated  flap 
from  the  opposite  leg. 


SURGERY  OF  THE  LOWER  EXTREMITY 


695 


on  the  leg.  Pedunculated  flaps  may  also  be  employed,  and  give  the 
best  results,  especially  in  exposed  positions.  Flap  may  be  obtained 
from  the  inner  or  outer  portion  of  the  same  thigh,  depending  on  the 


Fig.   819. — Method   of   covering   the   anterior   surface   of   the   knee  with  a  flap  from  the 
other  leg  (Maas). — Note  the  position  of  the  legs  in  the  cast. 

position  of  the  ulcer,  and  may  be  sutured  over  the  defect  after  flexion 
of  the  leg  on  the  thigh;  from  the  opposite  thigh  for  the  inner  lower 
third  of  the  leg,  the  ankle  resting  across  the  opposite  knee;  from  the 
opposite  leg  for  the  inner  lower  third,  the  ulcerated  leg  being  crossed 


Fig.  820.  Fig.  821. 

Method  of  utilizing  pedunculated  flaps  from  the  opposite  leg  for  covering  defects. 
Fig.   820. — A  flap  from  the  under  surface  of  the  opposite  leg  to  cover  the  knee  (Maas). 
Fig.   821. — A  flap  from  the  inner  side  of  the  opposite  leg  to  cover  a  defect  on  the  middle 
third  of  the  back  of  the  leg. 


diagonally  over  the  other  leg;  from  the  opposite  leg  for  the  outer  lower 
third,  the  normal  leg  being  crossed  over  the  ulcerated  limb.  All 
of  these^positions  may  be  varied  to  suit  existing  conditions. 


696 


PLASTIC    SURGERY 


ANKLE 


Loss  of  Substance.^ The  foot  slightly  inverted  should  be  put 
up  at  right  angles  to  the  leg  for  all  losses  of  substance  in  this  region. 
Wounds  or  ulcers  around  the  ankle  and  over  the  malleoli  are  difiicult  to 
heal.  If  skin  grafting  seems  inadvisable,  a  pedunculated  flap  should  be 
used  from  the  same  leg  or  from  the  selected  portion  of  the  other  leg,  if 
the  wound  is  of  any  size.  In  cases  of  small  losses  of  substance  the 
surrounding  skin,  if  normal,  may  be  undercut,  and  the  tissues  drawn  in 
and  sutured.  If  relaxation  incisions  are  necessary  the  resulting  defects 
may  be  grafted. 


Fig.  822. — Contracture  of  the  knee  following  an  extensive  burn.  Duration  two  years. 
I.  Note  the  extensive  destruction  of  tissue  and  the  areas  on  the  thigh  which  had  been  grafted. 
Also  the  mass  of  scar  tissue  filling  the  popliteal  space  and  preventing  extension.  2  and  3 
Result  of  the  reconstruction  of  the  popliteal  space  by  shifting  in  available  flaps,  and  skin 
grafting  the  remaining  areas.     Photograph  taken  six  months  after  operation. 


FOOT 

Loss  of  Substance. — Wounds  on  the  foot  require  active  assistance 
in  healing  if  the  best  functional  results  are  to  be  obtained.  On  the 
dorsum,  skin  grafting  is  usually  sufficient  except  over  the  instep,  where 
the  result  may  not  be  stable  unless  a  whole-thickness  graft  is  employed. 
In  this  situation  a  pedunculated  flap  from  adjacent  skin,  or  from  the 
other  leg,  may  be  necessary.  On  the  sole,  we  frequently  have  deep 
destruction  of  soft  parts,  and  this  is  especially  serious  when  it  involves 
the  covering  of  the  heel  and  other  weight-bearing  portions.  In  these 
situations  skin  grafting  is  a  waste  of  time,  the  only  satisfactory  results 
being  obtained  by  the  use  of  a  thick  pad  of  skin  and  fat  from  the  other 
leg. 


I 


SURGERY  OF  THE  LOWER  EXTREMITY 


697 


Contractures.  Thigh  and  Leg. — We  find  at  times,  following  burns, 
all  degrees  of  contracture  of  the  joints  of  the  lower  extremity.  The 
thigh  may  be  completely  flexed  on  the  abdomen  and  held  immovable  by 
a  vast  mass  of  scar  tissue;  the  leg  may  be  flexed  on  the  thigh,  the  foot, 
on  the  leg,  etc.  All  gradations  may  be  found  between  this  extreme 
grade  and  that  of  slight  Hmitation  of  motion. 


Fig.  823. — Extensive  third  degree  burns  of  both  legs  and  feet,  and  the  left  thigh. — 
First  seen  six  months  after  the  accident.  Note  the  exuberant  granulations.  Also  the 
flexion  of  the  left  knee  and  ankle  due  to  scar  tissue  contraction,  and  the  right  knee  due  to 
posture.  The  extent  of  spontaneous  healing  from  the  edges  can  be  seen,  especially  on  the 
right  leg  and  ankle.  The  legs  and  ankle  were  straightened  and  the  wounds  were  much 
improved  by  grafting.      Unfortunately  the  child  died  from  acute  uremic  poisoning. 

Treatment. — The  ideal  method  of  treatment  in  all  situations  is  the 
complete  excision  of  the  contracting  scar,  but  in  many  cases,  on  account 
of  its  extent,  this  is  impossible.  In  these  instances  division  down  to 
normal  tissue  and  relief  of  the  faulty  position,  with  immediate  grafting, 


698 


PLASTIC    SURGERY 


Fig.  824. — Delbet's  method  of  utilizing  a  flap  from  the  opposite  thigh  to  form  a  band  of 
elastic  skin  in  a  burn  involving  the  whole  circumference  of  the  leg. — The  rest  of  the  granulat- 
ing surface  is  grafted.  The  flap  as  illustrated  is  so  long  that  a  large  portion  would  slough 
unless  its  circulation  was  assured  b>  one  of  the  methods  described  in  the  text. 


Fig.  825. — The  use  of  a  wire  cage  in  the  treatment  of  an  ulcer  of  the  leg. — Note  the 
thick  felt  padding  and  the  method  of  securing.  The  cage  may  be  used  when  exposure  to  the 
air  is  desired,  or  for  purposes  of  protection. 


Fig.   826. — Position  assumed  when  covering  a  loss  of  tissue  on  the  inner  lower  third  of 
the  leg  by  a  flap  from  the  opposite  thigh. 


SURGERY  OF  THE  LOWER  EXTREMITY 


699 


Fig.  827.  Fig.  828. 

Figs.  827  and  828. — Position  assumed  in  obtaining  flaps  from  the  same  thigh  to  cover 
defects  on  the  leg. — This  is  a  very  irksome  position  and  should  only  be  used  in  exceptional 
cases. 


Fig.  829.  Fig.  830. 

Figs.   829  and  830. — Position  assumed  in  obtaining  flaps  from  the  opposite  leg  for  cover- 
ing defects  on  the  inner  and  outer  surfaces  of  the  lower  third  of  the  leg. 


Fig.  831. — Method  of  closing  a  deep  cavity  in  the  lower  end  of  the  tibia  following 
osteomyelitis. — (I  operated  on  this  case  at  the  Rockefeller  War  Demonstration  Hospital 
at  the  request  of  Major  G.  A.  Stewart,  U.  S.  A.)  The  defect  was  the  full  depth  of  the 
marrow  cavity,  and  was  somewhat  undermined  below.  The  surrounding  skin  was  in- 
filtrated with  scar  tissue.  On  account  of  the  age  of  the  patient  (over  sixty  years)  I  did 
not  feel  justified  in  using  a  pedunculated  flap  from  the  other  leg,  so  it  was  determined  to 
try  a  pedunculated  flap  from  adjacent  tissue  in  spite  of  its  inflltration  with  scar. 


yoo 


PLASTIC    SURGERY 


or  the  interposition  of  a  pedunculated  flap,  is  indicated.  It  is  sometimes 
impossible  to  obtain  pedunculated  flaps  from  the  same  thigh,  the 
opposite  thigh,  or  leg,  on  account  of  scar  tissue  covering  all  of  these 
areas,  and  if  a  pedunculated  flap  is  indicated  in  such  cases  it  has  to  be 
obtained  by  a  double  transfer. 

Some  of  the  most  vicious  contractures  with  which  we  have  to  deal 
are  found  around  the  knee-joint.  These  vary  from  complete  oblitera- 
tion of  the  popKteal  space,  with  fusion  of  that  portion  of  the  leg  and 


Fig.  832. — Method  of  closing  a  bone  cavity,  continued. — The  wound  had  been  pre- 
pared v.-ith  Dakin's  solution  and  was  sterile.  The  flap  from  below  and  behind  the  defect 
(with  its  pedicle  above  and  posterior;,  was  raised  and  turned  into  the  defect.  It  was  so 
rigid  on  account  of  scar  tissue  that  it  cotild  not  be  fitted  down  into  the  cavity.  This  diffi- 
culty was  overcome  by  filUng  the  cavity  with  a  free  fat  graft  from  the  thigh,  and  the  flap 
was  sutured  over  this.  The  defect  from  which  the  flap  was  raised  was  grafted  with  Ollier- 
Thiersch  grafts.  The  photograph  shows  the  flap  held  with  horsehair  sutures  and  the 
grafts  in  position. 


thigh,  to  much  less  severe  contractures  with  differing  amounts  of  loss 
of  function. 

In  old  cases  of  contractures  in  flexion,  tenotomy  or  lengthening  of 
the  hamstring  tendons  may  be  necessary.  After  relief  of  the  contracture 
the  leg  should  be  extended  slowly  in  order  to  stretch  gradually  the 
arteries  and  nerves.  The  defect  should  then  be  filled  with  a  pedun- 
culated flap,  as  described  under  loss  of  substance  for  this  region. 

Morestin's  method  of  excising  a  granulating  wound  or  contracture 


SURGERY  OF  THE  LOWER  EXTREMITY 


;'oi 


Fig.  S33. — Method  of  closing  a  bone  cavity,  ionliniied. — The  flap  has  lived  and  fills 
the  defect.  A  portion  of  the  fat  graft  broke  down.  The  Ollier-Thiersch  grafts  were  also 
successful.  The  result  was  relief  of  a  long  standing  defect,  and  shows  that  much  can  be 
accomplished  with  a  scar  infiltrated  flap.  The  procedure  would  have  been  quite  a  usual 
one  if  the  surrounding  skin  had  been  normal. 


Fig.  834. — Painful,  unstable  adherent  scar  over  the  tendo  Achillis. — i.  Note  the 
puckering  of  the  skin  due  to  deep  adhesions  over  the  upper  portion  of  the  scar.  The  scar 
was  completely  excised.  A  relaxation  incision  was  made  just  behind  the  external  malleolus, 
and  the  skin  and  fat  were  loosened  and  shifted  backward.  This  made  closure  without 
tension  possible.  The  defect  left  by  the  spreading  of  the  relaxation  incision  was  immedi- 
ately grafted.  2.  Note  the  healing  over  the  tendo  Achillis,  and  the  healed  relaxation  defect 
after  one  month  has  elapsed. 


702 


PLASTIC    SURGERY 


Fig.  835. — Contracture  of  the  foot  following  a  burn.  Duration  eighteen  months. — i. 
Note  the  flexion  of  the  foot  on  the  ankle,  and  the  eversion  of  the  sole  of  the  foot.  2.  The 
result  of  a  plastic  operation,  with  Ollier-Thiersch  grafting  of  the  remaining  defect. 


Fig.  836. — Contracture  of  the  foot  with  marked  distortion  of  the  toes  due  to  a  burn. 
Duration  seven  years. — i  and  2.  Note  the  position  of  the  foot.  The  boy  walks  on  his 
heel.  The  arrow  indicates  the  position  of  the  toes.  3.  Result  of  plastic  operation  with 
shifting  of  flaps  and  grafting  the  denuded  surfaces.  The  distorted  toes  may  now  be  seen 
more  plainly,  but  will  not  be  interfered  with  until  the  patient  has  been  walking  for  some  time. 


SURGERY  OF  THE  LOWER  EXTREMITY 


703 


in  the  groin  or  popliteal  space,  and  suturing  the  normal  skin  edges  with 
subsequent  gradual  stretching  of  the  skin,  may  be  used  in  selected 


cases. 


Fig.   837.  Pig.  838. 

Fig.   837. — Method  of  restoring  a  portion  of  the  sole  of  the  foot  by  means  of  a  peduncu- 
lated flap  from  the  other  leg  {Ombredanne). — Note  the  posture. 

Fig.   838. — Method  of  covering  a  heel  defect  with  a  flap  from  the  other  leg  (Maas). 


Fig.  839. — Painful  scar  of  heel  following  destruction  of  the  soft  parts  in  an  accident. 
Duration  three  years. — i.  The  scar  involving  the  heel  and  inner  side  of  the  foot  below  the 
malleolus.  The  patient  was  unable  to  bear  her  weight  on  the  heel  on  account  of  the  pain. 
2.  The  scar  over  the  heel  was  excised  and  a  pedunculated  flap  from  the  other  leg  was  im- 
planted.     Note  the  position  of  the  parts  in  the  plaster  cast. 

I  have  seen  a  number  of  instances  of  complete  scarring  of  the  leg 
in  which  only  limited  flexion  was  possible  on  account  of  the  tightly 


704 


PLASTIC    SURGERY 


drawn  scar  over  the  anterior  portion  of-  the  joint.  This  can  be  cor- 
rected by  dividing  the  scar  and  implanting  a  whole-thickness  graft  or 
a  pedunculated  flap. 


Fig.  840. — Painful  .scar  of  the  heel,  continued. — i.  The  flap  in  position  immediately 
before  cutting  the  pedicle,  twelve  days  after  operation.  Note  the  pedicle  of  the  flap  on  the 
leg  beneath,  and  its  insertion  into  the  heel  defect.  2.  Patient  standing  on  the  heel  three 
months  after  operation.      Note  the  soft  pad  imder  the  heel. 

Ankle  and  Foot. — We  often  see  contractures  of  the  foot  and  ankle 
following  extensive  denudations  or  burns.  If  flexion  is  complete,  the 
dorsum  of  the  foot  being  bound  to  the  ankle,  we  must  relieve  the 
contracture  and  fill  the  defect  with  a  graft,  or  with  a  pedunculated  flap, 


Fig.  841. — Painful  scar  of  heel,  continued. — i.  Taken  two  and  a  half  years  after  opera- 
tion. 2.  The  position  assumed  during  the  transfer  of  the  flap.  Note  the  flap  and  the 
defect  from  which  it  was  taken.  This  result  is  particularly  satisfactory  as  it  has  allowed 
the  patient  to  resume  her  occupation,  and  to  walk  without  pain. 

the  foot  in  the  meantime  being  placed  in  a  position  of  slight  extension. 
If  the  contracture  is  in  extension,  the  scar  must  be  divided  and  in 
many  instances  the  tendo  Achillis  lengthened.  The  foot  is  then  .placed 
in  a  slightly  flexed  position,  and  the  defect  filled  with  a  graft  or  a 
pedunculated  flap  from  the  neighborhood,  or  from  the  other  leg. 


SURGERY    OF    THE    LOWER    EXTREMITY 


705 


In  those  cases  in  which  there  is  permanent  flexion  or  extension  of 
the  toes  due  to  scar  tissue  the  contracture  should  be  relieved,  and  the 
defect  tilled  with  a  graft  or  flap 


Fig.  842. — Method  of  constructing  the  sole  of  a  foot  by  the  use  of  pedunculated  flaps 
from  the  other  leg. — i.  The  sole  of  the  left  foot  is  covered  with  a  thin  painful  scar  which 
is  immediately  over  the  bones  and  ligaments.  The  patient  has  been  unable  to  bear  her 
weight  on  the  foot  since  the  accident,  four  years  previously.  Compare  the  defective  foot 
with  the  normal  one.  The  only  method  which  promised  the  slightest  chance  of  success 
was  the  implantation  of  pedunculated  flaps  of  fat  and  skin  from  the  other  leg.  The  sole 
could  not  be  covered  vnth  a  single  flap.  2.  The  foot  secured  to  the  opposite  leg  during  the 
implantation  of  the  first  (anterior)  flap.      Note  the  position  which  was  quite  comfortable. 

On  the  sole  of  the  foot  we  frequently  find  practically  all  of  the  soft 
tissue  destroyed,  and  the  weight-bearing  bony  prominences  covered 
with  a  thin  tight  scar  which  is  constantly  ulcerating,  so  that  on  account 


Fig.  843. — Construction  of  the  sole  of  a  foot,  continued. —  i.  Position  assumed  during 
the  implantation  of  the  first  flap.  2.  The  result  of  the  first  implantation,  one  month 
after  ooeration. 


of  the  lack  of  protection  to  the  bones  it  is  impossible  to  bear  the  weight 
of  the  body  on  the  foot.  In  these  cases  we  must  supply  a  thick  pad 
of  skin  and  fat  to  cover  the  sole,  and  this  is  best  done  by  using  peduncu- 


7o6 


PLASTIC    SURGERY 


Fig.  844.- — Construction  of  the  sole  of  tlie  foot,  continued. — i.  Position  assumed  during 
the  implantation  of  the  second  flap,  six  months  after  the  first  operation.  2.  The  result  of 
the  second  implantation,  three  weeks  after  dividing  the  pedicle  and  fitting  it  into  position. 


Fig.  845. — Construction  of  the  sole  of  a  foot,  continued. — i.  Third  operation,  seven 
months  later.  Position  assumed  during  the  implantation  of  the  flap  over  the  heel.  2. 
The  scars  on  the  opposite  leg  showing  the  areas  from  which  the  flaps  were  taken.  These 
areas  were  grafted.  The  first  flap  was  taken  from  the  central  area;  the  second  from  the 
lower  area,  and  the  third  from  the  upper.  The  result  in  this  case  was  far  better  than  could 
have  been  obtained  by  an  artificial  foot,  which  was  the  only  alternative. 


Fig.  846. — Construction  of  the  sole  of  the  foot,  continued. — The  result  of  the  implanta- 
tions, taken  one  year  after  the  final  operation.  The  patient  has  been  able  to  walk  about 
without  pain  and  has  a  useful  foot.  The  scars  between  the  flaps  can  be  removed  and  the 
soft  edges  of  the  flaps  united,  which  will  improve  conditions. 


SURGERV  OF  THE  LOWER  EXTREMITY 


707 


lated  flaps  from  the  other  leg  fMaas.  Ombredanne  and  others).  After 
removal  of  the  scar,  if  the  circulation  of  the  bone  seems  poor,  it  is 
advisable  to  chisel  off  the  surface  down  to  the  spongy  portion,  and  to 
apply  the  flap  directly  to  this  area  where  the  circulation  is  good. 


Fig.  847. — X-ray  burn  <:,:  ::-e  -  '.c  .:  :;ie  f^iOt.  Duration  one  year. —  i.  The  condition 
of  the  burnt  area.  Constant  intense  pain,  and  frequent  breaking  down  were  the  principal 
causes  of  complaint.  The  entire  area  was  excised  down  to  normal  tissue.  A  pedunculated 
flap  from  the  back  of  the  other  leg  was  implanted.  2.  The  position  assumed  to  bring  the 
flap  into  the  defect.  The  pedicle  of  the  flap  was  close  to  the  foot.  Photograph  taken 
twenty  months  after  transplantation  of  the  flap.  The  area  from  which  the  flap  was  taken 
had  been  grafted.  Note  this  area  and  its  relation  to  the  flap.  3.  The  flap  in  position 
twenty  months  after  transplantation.  The  skin  of  the  flap  is  normal  in  appearance.  The 
flap  is  soft,  movable,  and  is  on  the  level  with  the  surrounding  skin.  All  pain  has  disap- 
peared and  the  result  is  satisfactory. 

Sometimes  the  pad  under  the  heel  alone  is  destroyed,  or  a  portion 
of  the  sole.  In  all  of  these  situations  I  have  been  able  to  supply  a 
thick  pad  from  the  other  leg.  and  in  this  way  a  useful  weight-bearing 
foot  has  been  made. 


7o8 


PLASTIC    SURGERY 


Unless  a  pad  can  be  supplied  when  the  soft  tissue  of  extensive  areas 
of  the  sole  has  been  destroyed,  it  is  advisable  to  amputate.  An  arti- 
ficial foot  will  be  infinitely  more  useful  than  one  which  causes  exquisite 
pain  whenever  any  weight  is  placed  upon  it. 


Fig.  848. — Schematic  drawing  to  show  the  aperiosteal  method  of  treating  the  bone 
in  amputation  stumps. — i.  The  periosteum.  2.  The  bone.  3.  The  marrow.  Note 
that  the  periosteum  and  bone  marrow  are  removed  from  the  bone  for  the  same  distance, 
actually  about  i.  cm.  (%  inch)  from  the  saw  line. 


AMPUTATIONS 

The  Aperiosteal  Method  of  Treating  the  End  of  the  Bone  in  Ampu- 
tations.— ^When  amputation  has  been  necessary  either  as  a  primary 


Fig.  849. — Ulcer  on  an  amputation  stump. — In  this  case  there  was  too  much  tension  on 
the  skin  flaps  and  sloughing  occurred.  The  skin  edges  might  be  brought  much  closer  by 
continuous  elastic  traction  and  the  area  grafted;  the  area  could  be  excised  and  the  edges 
approximated,  or  if  conditions  indicated  the  necessity,  a  pedunculated  flap  from  the  other 
leg  or  thigh  might  be  used  to  fill  the  defect. 

procedure  or  for  stump  shortening,  Lyle  and  others  have  emphasized, 
and  my  own  experience  supports  their  view,  that  the  aperiosteal 
method  of  treating  the  end  of  the  bone  is  the  simplest  and  in  the  end 


SURGERY  OF  THE  LOWER  EXTREMITY 


709 


the  most  satisfactory.  The  periosteum  is  removed  for  a  distance  of 
about  I.  cm.  (%  inch)  above  the  saw  Hne,  and  the  medullary  canal  is 
curetted  out  for  the  same  distance.  This  gives  a  painless  stump  and 
prevents  the  formation  of  bony  spicules. 


Fig.  850. — The  use  of  pedunculated  flaps  to  cover  amputation  stumps  (Hans). — 
The  dark  lines  indicate  the  outlines  of  flaps.  Flaps  of  almost  any  shape  and  size  may  be 
raised  from  any  desired  position  with  pedicles  above  or  below. 

Unhealed  Amputation  Stumps. — The  problem  of  healing  a  sluggish 
wound  on  an  amputation  stump,  or  of  covering  a  poorly  protected 
stump  with  a  pad  of  skin  and  fat  is  often  presented. 


Fig.  851. — Method  of  covering  a  defective  stump  with  a  flap,  pedicle  downward,  of 
skin  and  fat  from  the  other  leg. — This  same  type  of  flap  may  be  obtained  from  any  desired 
level  and  the  direction  of  the  pedicle  may  be  varied  to  suit  conditions. 

Healing  may  be  hastened  by  excision  of  the  area  and  grafting,  or 
better  still  by  means  of  a  pedunculated  flap  from  the  abdominal  or 
thoracic  walls  for  the  upper  extremity,  or  from  the  other  leg  or  thigh 


yio 


PLASTIC    SURGERY 


if  the  lower  extremity.  If  the  stump  is  poorly  padded,  the  end  after 
being  freshened  may  be  buried  in  a  pocket,  or  under  a  bridge  flap  of 
skin  and  the  full  thickness  of  the  underlying  fat  in  a  convenient  situa- 


PiG.  852. — Kinematic  plastic  amputation  of  the  arm  (A.  P.  C.  Ashhurst:  Annals  of 
Surgery,  December,  1914). — -i.  Inner  surface  of  the  arm.  The  flap  of  skin  and  subcuta- 
neous fat  AB  is  to  cover  the  end  of  the  bone.  A  circular  amputation  is  done  at  CD. 
2.   Outer  surface  of  the  arm.     The  flap  AB  is  sutured  to  the  line  A'B'. 

tion,  and  in  due  time  this  mass  of  tissue  may  be  transferred  to  the 
stump,  which  it  covers  with  a  soft  resistant  pad.  A  similar  method 
may  be  used  to  lengthen  the  stump  by  wrapping  a  cuff  of  skin  and  fat 
around  the  bone. 


:<CUT  END  OF  BICEPS 


CUT  END  OF  TWCEPS 


Pig.  853. — Kinematic  plastic  amputation  of  the  arm  (A.  P.  C.  Ashhurst:  Annals  of 
Surgery,  December,  1914). — i.  Diagrammatic  view  of  the  end  of  the  stump.  The  flap  AB, 
is  sutured  to  the  line  A'B'.  The  skin  overlying  the  muscular  flaps  is  sutured  around  them 
as  a  cylinder.  2.  The  biceps  has  been  sutured  to  the  triceps,  and  a  rubber  tube  is  passed 
through  the  loop  before  suturing. 


KINEMATIC  PLASTICS 

The  possibility  of  utilizing  the  muscles  of  the  stump  to  impart 
movement  to  an  artificial  limb  was  first  advanced  by  G.  Vanghetti 
(an  Italian  physician),  in  1896.     In  a  series  of  papers  since  then  he  has 


SURGERY  OF  THE  LOWER  EXTREMITY 


711 


again  and  again  advanced  his  theory,  but  up  to  the  time  of  the  great 
war  there  had  probably  been  only  about  twenty  cases  treated  along 
the  lines  suggested  by  him.     The  great  number  of  cases  requiring 


Fig.  S54. — Sauerbruch's  method  of  lining  the  muscle  loop  with  a  pedunculated  flap  of 
skin*(Gandiani:  Annals  of  Surgery,  Apr.,  1918). —  i.  Xote  the  situation  from  which  the 
skin  flap  is  taken  and  the  lines  marking  the  openings  of  the  tunnel  through  the  muscle. 
2.  The  flap  made  into  a  tube,  skin  side  inward,  and  being  drawn  through  the  tunnel  in  the 
muscle.     3.   The  skin  tube  in  position  and  wounds  closed. 


Fig.  855.  Fig.  856. 

Types  of  motor  flaps. 
Fig.  855. —  Codivilla's  knob  motor  flap  for  the  foot  (Gaudiani:  Annals  Surgery,  Apr., 
1918). 

Fig.  856. — Sauerbruch's  double  motor  loop. — The  dotted  lines  indicate  the  channels 
through  the  muscle  masses  (Gaudiani:  Annals  of  Surgery,  Apr.,  1918). 

amputation  during  the  last  four  years  has  enabled  surgeons  to  test  out 
and  prove  the  soundness  of  his  ideas. 


712  PLASTIC    SURGERY 

By  kinematic  plastics  is  meant  any  kind  of  procedure  by  which 
muscular  masses  can  be  used  to  carry  voluntary  movement  to  the 
artificial  limb.  Every  moving  portion  thus  obtained  is  called  a  plastic- 
motor  (motor  flap). 

Nearly  all  forms  of  motor  flaps  are  of  two  types,  the  loop  and  the 
knoh;  they  may  be  single,  double  or  multiple.  The  movements  may 
be  in  one  direction  only  (unimotor) ,  or  the  motor  flap  may  execute  two 
opposite  movements  in  succession  (plurimotor) .  If  the  motor  flap  is 
on  the  extremity  of  the  stump  it  is  called  terminal;  if  on  the  continuity 
of  the  stump  it  is  called  extraterminal. 

The  method  may  be  employed  on  the  upper  or  lower  extremities. 
Under  ideal  conditions  the  motor  flaps  may  be  formed  at  the  primary 
operation.  Nevertheless  if  conditions  are  not  favorable,  every  particle 
of  viable  tissue  should  be  preserved  for  future  use,  and  the  muscles  and 
tendons  sutured  over  the  bone  end  in  order  to  preserve  their  function. 
The  motor  flaps  may  then  be  formed  later.  They  must  be  firm  and 
resistant,  and  must  contain  enough  functional  muscle  itssue  to  carry 
out  the  demands  placed  upon  them.  The  plastic  surgeon  may  be  of 
use  to  the  orthopedist  in  planning  the  shapes  and  in  covering  and 
lining  these  motor  flaps  with  skin,  which  must  be  in  perfect  condition. 
The  skin  must  have  the  proper  blood  and  nerve  supply,  in  order  that 
it  may  withstand  the  strain  which  will  be  put  upon  it,  as  the  whole 
procedure  will  be  a  waste  of  time  unless  the  flaps  are  suitably  covered 
with  skin.  The  artificial  limb  is  usually  secured  to  the  knobs  by  means 
of  straps,  and  to  the  loops  by  means  of  hooks,  rings,  rods,  or  cords. 
The  orthopedic  technic  will  not  be  considered  here.  I  believe  that  this 
method  will  become  more  and  more  effective  as  the  mechanism  of 
artificial  limbs  becomes  perfected. 

The  ordinary  principles  of  flap  making  and  shifting  must  be  em- 
ployed in  covering  the  motor  flaps  with  skin,  and  the  loops  in  old 
stumps  may  be  lined  with  pedunculated  flaps  sutured  in  the  form  of  a 
tube  with  skin  surface  inward,  much  in  the  same  way  as  in  forming  a 
urethra  with  a  pedunculated  flap  from  the  scrotum.  This  skin-lined 
tube  is  then  pulled  through  the  channel  prepared  for  it,  or  the  muscle 
flaps  are  closed  around  it. 

ELEPHANTIASIS 

Etiology.— In  the  United  States  this  condition  is  seldom  met  with  as 
a  result  of  obstruction  of  the  lymph  vessels  by  the  filaria  bancrofti. 
Matas  believes  that  venous  or  lymphatic  stasis  followed  by  bacterial 


SURGERY  OF  THE  LOWER  EXTREMITY  713 

invasion — usually  streptococcic — is  necessary  to  produce  true  elephan- 
tiasis, and  gives  the  following  conditions  as  essential  in  producing  the 
picture:  (i)  A  mechanical  obstruction  or  blockage  of  the  veins  and 
lymphatics  of  the  region,  usually  an  obliterative  thrombo-phlebitis, 
lymphangitis  or  adenitis;  (2)  hyperplasia  of  the  collagenous  connective 
tissue  of  the  hypoderm;  (3)  gradual  disappearance  of  the  elastic  fibers 
of  the  skin;  (4)  the  existence  of  a  coagulating  dropsy  or  hard  lymph- 
edema; (5)  a  chronic  reticular  lymphangitis  caused  by  secondary  and 
repeated  invasions  of  pathogenic  microorganisms  of  the  streptococcal 
type. 

Treatment. — As  the  streptococcus  is  so  closely  associated  with  the 
etiology  of  elephantiasis,  and  as  attacks  of  erysipelas  so  frequently 
occur,  it  is  advisable  to  inject  antistreptococcus  serum  or  vaccine 
before  and  after  operation,  once  or  several  times  according  to  the  indi- 
cations. The  toilet  of  the  skin  must  be  most  carefully  looked  after, 
and  all  folds  thoroughly  disinfected.  S.  Handley,  in  1908,  introduced 
a  method  which  he  called  "lymphangioplasty"  and  which  he  used  to 
reduce  the  size  of  edematous  arms,  such  as  occur  after  the  operations  for 
the  removal  of  the  breast  for  carcinoma.  The  tissues  of  the  arm  are 
drained  by  two  long  "hairpin-shaped"  lines  of  silk  placed  in  the  sub- 
cutaneous tissue,  one  on  the  flexor  and  one  on  the  extensor  surface. 
The  bends  of  the  "hairpins"  lie  immediately  above  the  wrist,  and  the 
long  portions  of  the  threads  are  placed  on  each  side,  so  that  a  thread  is 
inserted  at  each  quadrant.  Toward  the  shoulder  the  lines  of  silk  on 
the  flexor  side  curve  outward  toward  the  deltoid  muscle  and  converge 
with  the  threads  from  the  posterior  aspect  at  the  posterior  border  of  the 
deltoid.  From  this  point  the  threads  radiate  into  the  subcutaneous 
tissue  of  the  scapular  region.  The  early  results  of  this  method  were 
very  encouraging  when  used  in  the  arm  or  leg,  but  recurrence  soon 
followed.  The  later  results  are  unsatisfactory,  and  Madden,  Ibrahim 
and  Ferguson  found  that  the  threads  were  soon  completely  blocked  off 
by  scar  tissue,  and  that  in  consequence  all  drainage  from  this  source 
was  obliterated. 

Kondoleon  in  191 2,  developed  a  method  based  on  the  good  points  of 
several  other  procedures,  which  is  at  once  the  most  radical  and  the 
most  promising  for  the  relief  of  this  condition.  The  modified  technic, 
used  at  the  Mayo  Clinic  and  reported  by  Sistrunk,  is  the  most  satisfac- 
tory procedure  for  carrying  out  the  method  (Fig.  857-63). 

The  object  of  this  operation  is  to  allow  the  deeper  group  of  lymphatics 


714                                                       PLASTIC    SURGERY 

exposed  by  the  removal  of  the  deep  fascia  to  drain  the  tissue  ordinaril} 
taken  care  of  by  the  blocked  superficial  group. 

A  long  modified  elliptic  incision,  which  includes  the  skin  to  be 
removed,  is  made  on  one  side  of  the  limb.     For  example,  on  the  outei 
aspect    of    the   lower  extremity  this  incision  would  extend  from  the 

,  ^^p*9*^p? 

/I  n.  c  i  5  i  0  Tbvj 

Oleoranoib    t<voQ9-i^    oj'    ixl'-bO* 

X                                                          ^^ 

— 

ess 

styloid    proc 

of     uxuTTjer-as   ■■ 

Fig.   857- 


TL  C  1  S  !>  0  n>' 


cT    ii,i,n.aj 


iTv-feerrbObL    Gon,dijle 


a'arri.erii.s 


Fig.   858. 
Kondoleon's  operation  for  elephantiasis  (Sistrunk). 
Pig.  857. — The  dark  lines  indicate  the  incisions  on  the  outer  surface  of  the  arm  and 
forearm. 

Pig.  858. — The  dark  lines  indicate  the  incisions  on  the  inner  surface  of  the  arm  and 
forearm. 


trochanter  to  the  external  malleolus.     In  order  to  facilitate  the  removal' 
of  the  subcutaneous  fat,  the  skin  is  undercut  on  each  side  of  the  incision 
for  2.5  or  5.  cm.  (i  or  2  inches).     The  edges  are  retracted  and  long 
parallel    incisions    are    made   through   the   edematous  fat  and  deep 
aponeurosis.     The  ends  of  these  incisions  are  connected  by  transverse 


SURGERY  OF  THE  LOWER  EXTREMITY 


715 


synvpKvjSii- 


interna  i» 

ucer35i.tij. 

T  e  m  u  r 


Fig.   859.  Fig.  860. 

Kondoleon's  operation  for  elephantiasis,  continued  (Sistrunk). 
Fig.   859. — The  dark  lines  indicate  the  incisions  on  the  outer  surface  of  the  leg  and  thigh. 
Fig.  860. — The  dark  lines  indicate  the  incisions  on  the  inner  surface  of  the  leg  and  thigh. 


Fig.  86i. — Kondoleon's  operation,  continued. — Incision  through  the  skin  and  super- 
ficial portion  of  the  subcutaneous  fat  used  on  outer  surface  of  the  leg  and  thigh.  The 
dotted  lines  A  and  B  show  the  extent  to  which  the  skin  is  undermined  for  the  removal  of 
the  subcutaneous  fat. 


?J5Sg^iS 


"^^^  Apon.ev.rosvs 


Fig.   863. 
Kondoleon's  operation  for  elephantiasis,  continued. . 
Fig.  862. — Shows  the  method  of  undercutting  used  to  remove  a  wide  area  of  subcuta- 
neous fat. 

Fig.   863. — Cross  section  of  Fig.  862.      The  dotted  lines  indicate  the  incisions  made  in 
removing  the  fat. 


SURGERY  OF  THE  LOWER  EXTREMITY 


717 


cuts.  The  mass  of  skin,  fat  and  deep  aponeurosis  is  then  removed, 
leaving  the  muscles  exposed.  (If  it  is  on  the  inside  of  the  lower 
extremity  the  internal  saphenous  vein  is  tied  off.)  All  bleeding  is 
checked,  and  the  wound  is  closed  without  drainage,  so  that  the  skin 
with  a  small  amount  of  subcutaneous  fat  comes  in  contact  with  the 
exposed  muscles.  If  the  condition  of  the  patient  permits,  the  other 
side  of  the  extremity  is  similarly  treated  immediately.  If  the  condition 
does  not  warrant  further  work,  the  second  operation  is  postponed  until 


Fig.  864. — Elephantiasis  of  the  right  leg  in  a  negress. — The  etiology  is  obscure.  The 
patient  has  had  a  leg  ulcer  off  and  on,  but  there  is  no  history  of  erysipelas.  No  filaria  could 
be  found.  The  thigh  was  only  slightly  enlarged  and  its  tissues  were  soft  and  apparently 
normal. 


a  suitable  time.     The  patient  is  allowed  to  get  up  ten  days  after  the 
operation,  the  part  being  supported  with  an  elastic  bandage. 

The  results  in  my  own  experience  with  Kondoleon's  operation 
have  been  only  fair.  Possibly  my  excisions  have  not  been  quite  so 
radical  as  those  in  the  operation  just  described,  and  this  may  explain 
why  I  have  not  secured  the  hoped  for  results.  In  one  of  my  cases,  a 
girl  of  22  years  first  noticed  a  swelling  of  the  right  leg  and  thigh  when 
she  was  17  years  old.  The  etiology  was  absolutely  obscure;  nothing 
could  be  found  in  the  history  or  by  physical  examination  to  account 
for  the  condition.  During  the  operation  on  this  case  I  had  great 
difficulty  in  checking  the  lymph  flow.  The  thigh  wound  would  fill  up 
with  a  straw-colored  fluid  which  seemed  to  come  from  the  entire  raw 


71 8  PLASTIC    SURGERY 

surface.  Finally  by  using  hot  packs  and  pressure  I  was  able  to  check 
the  flow  and  the  wound  was  closed.  In  the  same  case  the  subcutaneous 
fat  was  very  rigid,  and  the  deep  fascia  was  opaque  and  much  thickened, 
being  0.4  to  0.6  cm.  (about  }q  to  J4  inch)  thick  in  places. 

Sometimes,  when  great  folds  of  tissue  hang  down,  it  may  be 
necessary  to  excise  a  portion  of  them  in  order  to  allow  the  patient  to 
walk. 

I  saw  Dr.  Walton  Martin  operate  on  such  a  case  at  St.  Luke's 
Hospital  in  New  York.  He  removed  a  huge  mass  of  tissue  which 
enabled  the  woman  to  walk.  This  patient  had  previously  had  a 
similar  operation  with  temporary  relief,  and  it  seemed  probable  that 
further  operative  work  would  be  necessary. 

Amputation  has  been  done  on  several  occasions  for  extensive 
elephantiasis  (Wobus  and  Opie  and  others),  but  this  should  not  be 
undertaken  unless  all  other  methods  have  proved  useless. 

BIBLIOGRAPHY 

AsHHURST,  A.  P.  C.     "Anns.  Surg.,"  Dec,  1914,  750. 

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Beck,  E.  G.     "Surg.,  Gyne.  &  Obst.,"  March,  1918,  259. 
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Chapple,  W.  a.     "Brit.  IVJed.  Jour."     London,  Aug.  25,  191 7,  242. 
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Gaudiani,  V.     "Anns.  Surg.,"  April,  1918,  414. 

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HoESSLY,  H.     "  Correspondenz-Blatt  f.  Schweizer  Aerzte."     Basel,  April  27,  1918,  538. 

HuGGiNS,  G.     "Lancet."     London,  April  28,  191 7,  646. 

Jayle,  F.     "Presse  Med.,"  Aug.  23,  1917,  486. 

Lerda,  G.     "Policlinico."     Rome,  Aug.,  1917,  Surg.  Sec,  No.  8,  313. 
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MosTi,  R.     "Gaz.  degli  Ospedali  Cliniche."     Milan,  March  15,  191 7. 

Peraire.     "Soc.  de  chir.  de  Paris,"  Dec.  15,  1916. 
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PuTTi,  V.     "Chir.  degli  Organi  di  Movimento."     Bologna,  Dec,  191 7,  Nos.  4,  5,  6,  p.  409 
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Barber,  R.  S.     "Surg.,  Gyne.  &  Obst.,"  July,  1917,  104. 

Handi.ey,  W.  S.     "Brit.  Med.  Jour.,"  April  9,  1910,  853. 

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Madden,  F.  C  &  Ferguson,  A.  R.     "Brit.  Med.  Jour."     London,  191 2,  ii,  121 2. 
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